LCHD Auth for Release of Info

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION

1. Name of person requesting records: *This question is required.

2. Type of records being requested *This question is required.

Immunization Record
Copy of Immunization Exemption(exemption must be for current calendar year. LCHD does not have access to historical exemptions)
Medical Records
Other(please specify) Please enter an 'other' value for this selection. * This question is required.

3. Contact Phone Number: *This question is required.

4. Contact Email: *This question is required. This question requires a valid email address.

5. How would you like to receive the records? *This question is required.

6. I understand that it is my right under HIPAA laws to request access to my protected health information via my preferred method.

I request and authorize the Livingston County Health Department to send my protected health information (PHI) to me by unencrypted email.
I understand that unencrypted email is not a secure method of communication. By selecting this option and signing below, I acknowledge that I have been fully informed of the risks associated with receiving my PHI through unencrypted email, including but not limited to:

Emails can be intercepted during transmission by unauthorized individuals.
Emails may be accessed by third parties who gain access to my email account or devices.
Email providers may store messages on servers not controlled by my healthcare provider.
Emails may be misdirected to the wrong address due to typographical errors or technical issues.

I understand that these risks may result in the unintended disclosure of my PHI, including sensitive information.

Despite these risks, I still request and consent to have my PHI sent to me via unencrypted email. I accept full responsibility for any unauthorized access that may occur once the information has been sent according to my request.

I agree and consent to having my records sent in an unencrypted email to the email address listed here. Please enter an 'other' value for this selection. * This question is required.

To submit a record request, please fill out the form on the following page.
• Client Name and Date of Birth refer to the person whose records are being requested.
• Recipient Name(s) and Address(es) indicate who will receive the records. If you're a parent requesting records for your child, enter your own name and address in this section.