RHIA Practice Test 9

Authorization excerpt received by the HIM department (request from a life insurance company)

¹I authorize the Health Information Management department of the hospital to release the following information about me: discharge summaries, histories and physicals, laboratory results and psychotherapy notes for all admissions from three years ago to the present.

²Release to: the underwriting department of a life insurance company, at the mailing address listed below.

³Purpose: evaluation of my application for a life insurance policy.

⁴I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it. I understand that the hospital will not condition my treatment, payment, enrollment or eligibility for benefits on whether I sign. I understand that information disclosed under this authorization may be redisclosed by the recipient and may no longer be protected by federal privacy rules.

⁵Signature of patient: (signed) Date signed: September 14 of the current year