Hawaii Authorization to Disclose Protected Health Information Form
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ST. FRANCIS HEALTHCARE SYSTEM OF HAWAII

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AUTHORIZATION TO DISCLOSE
PROTECTED HEALTH INFORMATION
Patient's Name:

Date of Birth:

Telephone #:

1. By signing this Authorization form, I give permission to:
St. Francis Hospice
St. Francis Home Care Services
Other - Name:
Address:
2. To disclose my health information to:
Name:

Telephone:

Address:
3.

For the purpose of:

4. Type of record(s) to be disclosed:
Discharge summary

Pathology reports

Complete medical record

Medical history and physical

Emergency room records

Billing records

Consultation reports

X-ray and imaging reports

Operative reports

X-ray films

5. Dates of Treatment: From:

Other:

To:

6. I specifically authorize disclosure of the following restricted health information:
______Initials
Records containing information about HIV Infection, AIDS or AIDS Related Complex (ARC)
______Initials
Records containing information about diagnosis or treatment of a mental illness
______Initials
Records c