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PATIENT INFORMATION
Last Name: *
First Name: *
Date of Birth:*
Format: MM/DD/YYYY
Medical Record Number:
(if known)
Email Address: *
Primary Phone Number: *
Format: 555-555-5555
Secondary Phone Number:
Relationship:*

I hereby authorize UC Irvine Health to disclose Health Information from my Electronic Health Record to FollowMyHealth a Personal Health Record Vendor.
 
The data elements I authorize to be disclosed may include the following information:
• Ambulatory Visit Summary    • Allergies
• Immunizations • Medications
• Conditions • Patient Education and Instructions
• Documents • Routine Test Results

 
 Some of this information may contain reference to mental health, alcohol, drug abuse, sexually transmitted infections including HIV or AIDS and also results for developmental disabilities and or genetic testing. By placing your initials in this section you are authorizing UC Irvine Health to release these types of information to your Personal Health Record.
Patient Initials: *

Purpose of the requested use or disclosure is at your request for you to maintain your Personal Health Record.
Limitations, if any:


Purpose of the requested disclosure is for you to maintain your Personal Health Record.
This Authorization will expire on DATE:
If no date is indicated, the authorization will expire 5 years after the date of your last visit.

MY RIGHTS
  1. I understand this authorization is voluntary.
  2. This authorization may be revoked in writing at any time, except to the extent that action has been taken in reliance on this authorization.
  3. I may inspect or obtain a copy of the health information that I am being asked to use or disclose and I may inspect or obtain a copy of health information that is not being used or disclosed in the Personal Health Record.
  4. I understand that the health information in the Personal Health Record does not constitute my entire medical record and cannot be relied upon for clinical decision-making by a healthcare provider.
  5. I may revoke this authorization at any time, but I must do so in writing and submit it to:
    Health Information Management, 101 The City Drive, Orange, CA 92868
  6. I have the right to receive a copy of this authorization.
  7. Treatment, payment, enrollment or eligibility benefits may not be conditioned on signing this authorization.
Below is your electronic signature. Type your name to sign.
Patient Signature:*
Today's Date:
Time:
Signature:*
Today's Date:
Time:
Patient's Legal Representative, Guardian, Custodian, or Personal Representative




NOTICE: You have authorized the disclosure of your Health Information to a vendor who legally is required to keep the information confidential, and has signed an agreement with the University to secure and protect the information. Please carefully review the Terms and Conditions that FollowMyHealth will have you sign that explains how they will use and protect your health information. Physicians and many other organizations such as hospitals are required by law to keep the information confidential. If the information is later re-disclosed to someone who is not legally required to keep it confidential, it may no longer be protected by State or HIPAA federal confidentiality laws.
 
Questions? Please contact Health Information Department at 714-456-5670.