Bloom Healthcare Authorization To Release - CO


Bloom Health Care

 

10900 W 44th Ave, Suite 200
Wheat Ridge, CO 80033
Phone (303) 993-1330 • Fax (303) 647-3647

 

 

Authorization To Release Protected Health Information

Please review, sign and return.

 

I hereby authorize the following provider to disclose the above-named individual’s health information. I understand that the information in my health record may include information relating to communicable disease, Acquired Immunodeficiency Syndrome (AIDS), or Human Immunodeficiency Virus (HIV), genetic testing or screening, behavioral or mental health, alcohol/drug (substance) abuse or any such related information.

Name of Facility Releasing Information:

 

Provider to whom information will be released:

Bloom Healthcare
10900 W 44th Ave, Suite 200
Wheat Ridge, CO 80033

Please FAX requested information to (303) 647-3647 or mail to the above address

Purpose of disclosure:

TREATMENT

Information to be used/disclosed:
  • Progress notes
  • Consultations
  • Most recent history and physical
  • Immunization record
  • Laboratory reports
  • Radiology/Imaging reports
  • Radiology films
  • Two-way verbal exchange of communication
  • Entire medical record
  • Other:

Date Range of Information Disclosed

Start Date:
End Date:

 

By signing this authorization, I agree to the following:

  • I understand if I authorize my information to be released to persons or organizations not subject to federal privacy laws, the information may be re-disclosed by the recipient and the information will no longer be protected.
  • I understand that authorizing the use and disclosure of this health information is voluntary and that I can refuse to sign this authorization. I do not need to sign this form in order to receive treatment.
  • I understand that I may inspect a copy of the information to be used or disclosed.
  • I understand that I can revoke this authorization at any time by contacting my provider, but any revocation will not apply to the extent that my provider has acted in reliance of this authorization.
  • I authorize the use and disclosure of my health information as described above. This authorization expires one year from the date on which it was signed, unless otherwise specified. (Otherwise specified date, event, or condition: )

 

 

If not signed by patient, list personal representative’s authority to act for the patient:

Leave this empty:

Bloom Healthcare https://bloomhealthcare.com
Signature Certificate
Document name: Bloom Healthcare Authorization To Release - CO
Unique Document ID: 61262542082329353889f89ef257c61e9da5ebe1
Timestamp Audit
December 23, 2018 5:39 pm MDTBloom Healthcare Authorization To Release - CO Uploaded by Consent Team - consents@bloomhealthcare.com IP 98.245.131.4
January 2, 2019 12:52 pm MDTBloom Healthcare - consents@bloomhealthcare.com added by Bloom Healthcare - consents@bloomhealthcare.com as a CC'd Recipient Ip: 127.0.0.1
January 4, 2019 6:30 pm MDTBloom Healthcare - consents@bloomhealthcare.com added by Bloom Healthcare - noreply@bloomhealthcare.com as a CC'd Recipient Ip: 2601:281:c601:7b0:b0cf:b9ad:ee47:ce21
January 4, 2019 6:49 pm MDT Document owner noreply@bloomhealthcare.com has handed over this document to consents@bloomhealthcare.com 2019-01-04 18:49:44 - 2601:281:c601:7b0:b0cf:b9ad:ee47:ce21
January 4, 2019 6:49 pm MDTBloom Healthcare - consents@bloomhealthcare.com added by Consent Team - consents@bloomhealthcare.com as a CC'd Recipient Ip: 2601:281:c601:7b0:b0cf:b9ad:ee47:ce21
January 4, 2019 6:51 pm MDTBloom Healthcare - consents@bloomhealthcare.com added by Consent Team - consents@bloomhealthcare.com as a CC'd Recipient Ip: 2601:281:c601:7b0:b0cf:b9ad:ee47:ce21
February 4, 2019 5:29 pm MDTBloom Healthcare - consents@bloomhealthcare.com added by Consent Team - consents@bloomhealthcare.com as a CC'd Recipient Ip: 98.245.131.4
April 8, 2019 11:14 am MDTBloom Healthcare - consents@bloomhealthcare.com added by Consent Team - consents@bloomhealthcare.com as a CC'd Recipient Ip: 98.245.131.4
May 5, 2019 10:41 am MDTBloom Healthcare - consents@bloomhealthcare.com added by Consent Team - consents@bloomhealthcare.com as a CC'd Recipient Ip: 98.245.131.4
May 5, 2019 10:44 am MDTBloom Healthcare - consents@bloomhealthcare.com added by Consent Team - consents@bloomhealthcare.com as a CC'd Recipient Ip: 98.245.131.4
May 5, 2019 10:55 am MDTBloom Healthcare - consents@bloomhealthcare.com added by Consent Team - consents@bloomhealthcare.com as a CC'd Recipient Ip: 98.245.131.4
May 5, 2019 10:55 am MDTBloom Healthcare - consents@bloomhealthcare.com added by Consent Team - consents@bloomhealthcare.com as a CC'd Recipient Ip: 98.245.131.4
May 5, 2019 10:56 am MDTBloom Healthcare - consents@bloomhealthcare.com added by Consent Team - consents@bloomhealthcare.com as a CC'd Recipient Ip: 98.245.131.4
May 5, 2019 10:57 am MDTBloom Healthcare - consents@bloomhealthcare.com added by Consent Team - consents@bloomhealthcare.com as a CC'd Recipient Ip: 98.245.131.4