HIPAA Authorization for Release of Medical Information

1. Patient Information

Full Legal Name *

Date of Birth *

Address *

Phone Number

Email

2. Healthcare Provider / Facility Releasing Records

Provider/Facility Name *

Provider Address *

Phone

Fax

3. Authorized Recipient of Information

I authorize the above healthcare provider to release my information to:

Recipient Name *

Relationship *

Recipient Address *

Phone

Email

4. Information to be Released

Select the types of records to be released:

Complete Medical Records Medical History Laboratory/Test Results Imaging/Radiology Reports Prescription Records Immunization Records

Date Range - From

Date Range - To

Specific Records Description (Optional)

Sensitive Information (Requires Specific Authorization)

Check ONLY if you authorize release of the following protected categories:

Mental Health Treatment Records Alcohol/Drug Abuse Treatment Records HIV/AIDS-Related Information

5. Purpose of Disclosure

At my request / Personal use Continuing care / Treatment Insurance purposes Legal representation Disability determination Other (specify below)

6. Authorization Expiration

This authorization will expire:

On a specific date:

Upon the following event:

7. Patient Rights

Right to Revoke: I understand that I have the right to revoke this authorization at any time by submitting a written request to the healthcare provider named above. I understand that revocation will not affect information already disclosed pursuant to this authorization.

Voluntary Authorization: I understand that I am not required to sign this authorization. My treatment, payment, enrollment, or eligibility for benefits will not be conditioned on signing this authorization, except in limited circumstances permitted by law.

Re-disclosure Notice: I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations (HIPAA).

8. Signature

By signing below, I authorize the release of my protected health information as described above.

Signature *

Printed Name *

Date *

If signing on behalf of patient, state relationship: