Cliff Murry

Overall experience includes county and school social worker. Identifying and providing resources for youth and family. Collaboration with community resources including police and fire departments and nonprofit programs.

• To: Health Care Provider:
• I, Clifton A Murry, D.O.B. 1971-02-17
• 2102 Purple Aster Ln. Jonesville, WI 53546
• 1. Purpose: This form is to obtain an individual's consent under Wisconsin/Illinois law to verbally release information regarding a patient's healthcare, and/or copies of medical records, to individuals as designated by the patient. (This form should not be used to obtain consent for disclosure of mental health treatment records or HIV test results.)
• 2. Authorization: You are authorized to do the following:
• A. Verbally release my medical condition and/or treatment and prognosis.
• B. Provide copies of all documents and records in your possession regarding my medical condition and treatment, at any time, including medical history and findings, consultations, prescriptions, treatments, x-rays, radiology reports, special consultation reports, diagnosis and prognosis, as well as copies of all hospital, medical and billing records.
• 3. Provide Information To: The information identified in this document may be released to, or discussed with any of the following persons: Kyera Murry (262) 542-0381
• 4. When to provide Information: You are authorized to provide the information identified in this document at the request of the individual(s) identified in paragraph three (3) above.
• 5. Expiration: Unless otherwise revoked, this authorization will expire on the following date or event: _______________________. If I fail to specify an expiration date, this authorization will expire in six months. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and may not be protected by federal confidentiality rules.
• 6. Authority to Revoke: The undersigned reserves the right to revoke this authorization. In order to revoke this authorization, the notification must be written, signed by the undersigned and dated. The revocation will then become effective when received by Beloit Health System – Health Information Department.
• 7. Re-disclosure: I understand that the information disclosed by reason of this document may be subjected to re-disclosure by the recipient and therefore may no longer be protected under state or federal law.
• 8. Photostatic Copies: A photostatic copy of this authorization shall be considered as effective and valid as the original.
• 9. Voluntary Action: I understand that I am not required to sign this document and I am signing this document voluntarily. I understand that no treatment, payment, enrollment, or eligibility for benefits may be conditioned upon signing or failing to sign this authorization.
• 10. Privacy Waiver: With regard to the disclosure of information authorized in this document, I waive any right of privacy that I may have under the authority of the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191 (HIPAA), any amendment or successor to the Act, or any similar state or federal act, rule or regulation that might otherwise prevent any health care provider from providing access to my medical records under this document. Also, I hold harmless from any claim of liability under such act, rule or regulation, any medical provider who provides access to my medical information and records under this document.
• Dated: ______________________
• Signature: ______________________
• Print Name: Clifton Murry