Spreadsheet: 21719cea-cc13-47ee-b7ec-72d53196f93c
Sheet: Sheet1

Unnamed: 0 | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Authorization to Release Protected Health Information                                for Research Purposes. | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | Unnamed: 8 | Unnamed: 9 | Unnamed: 10 | Unnamed: 11 | Unnamed: 12
Patient Information | Full Name |  |  |  |  |  |  |  |  | Medical Record #
 | Address
 | City |  |  |  |  |  | State |  |  |  |  | Zip
 | Phone # |  |  |  |  |  | Date of Birth
 | I hereby authorize:
 | National Jewish Health - Main Campus 1400 Jackson St Denver, CO 80206  PH (303) 398-1580  FAX (303) 398-1211
 | NJH - Highlands Ranch 8671 S. Quebec St. Ste 120 Highlands Ranch, CO 80130  PH (303) 703-3646  FAX (303) 738-1385
 | NJH - South Denver 499 [NAME]. [NAME], CO 80113  PH (303) 788-8500  FAX (303) 788-8505
 | Other:
 |  |  | Name/Title Organization
 |  |  | Address
 |  |  | City/State/Zip |  |  |  |  | Phone |  |  | Fax
Release To | Release to:
 | National Jewish Health - Main Campus 1400 Jackson St Denver, CO 80206  PH (303) 398-1580  FAX (303) 398-1211
 | NJH - Highlands Ranch 8671 S. Quebec St. Ste 120 Highlands Ranch, CO 80130  PH (303) 703-3646  FAX (303) 738-1385
 | NJH - South Denver 499 [NAME]. [NAME], CO 80113  PH (303) 788-8500  FAX (303) 788-8505
 | Other: |  | National Jewish Health, ATTN: (Name of Contact), (Contact's Title)
 |  |  | Name/Title Organization
 |  |  | 1400 Jackson Street, (Building and room number of contact)
 |  |  | Address
 |  |  | Denver, CO  80206 |  |  |  |  | (Contact's phone) |  |  | (Contact's fax)
 |  |  | City/State/Zip |  |  |  |  | Phone |  |  | Fax
 | Other:
 |  |  | Name/Title Organization
 |  |  | Address
 |  |  | City/State/Zip |  |  |  |  | Phone |  |  | Fax
Purpose &                         PHI Disclosed | Continuation of Care       Insurance     Legal         Personal Use       Other |  |  |  |  |  |  |  |  | Research Participation in HS-(XXXX)
 | For Treatment Date(s) |  |  | (Nature of disease studied)
 | Clinic Summary/Consultation       Procedure           Laboratory/Radiology            Pulmonary Test         Cardiology Test
 | Other
Authorization | N/A | By initialing this area, I authorize the release of my health records that may include information indicating the presence of
 | communicable or veneral diseases, which may include, but are not limited to:  hepatitis, syphilis, gonorrhea and the human
 | immunodeficiency virus, also known as Acquired Immune Deficiency Syndrome (AIDS or Human Immune Deficiency Virus (HIV).
 | N/A | By initialing this area, I authorize the release of my health records that may include information about behavioral and/or mental
 | health services and/or treatment for alcohol and/or drug abuse.
 | This request is made voluntarily and the information given is accurate to the best of my knowledge.
 | I may revoke this authorization at any time in writing, but if I do, it will have no effect on actions taken prior to receiving the revocation.
 | I understand that information disclosed pursuant to the authorization may be subject to redisclosure by the recipient and is no longer protected by the HIPAA privacy rule.
 | Without my express revocation, this consent will automatically expire 180 days from the date signed below, unless I request an expiration date less than 180 days.
Signature | My signature is required to validate this Authorization.  If I sign this form, my health care, the payment for my health care or my ability to enroll for benefits will not be affected.
 | Patient or Authorized Representative Signature |  |  |  |  | Date |  |  | Relationship