Healthcare Background Release Form

HEALTHCARE BACKGROUND RELEASE FORM

Patient Name:    Date of Birth:

PATIENT INFORMATION

Female   Male   Other / Prefer not to say

INSURANCE INFORMATION

MEDICAL HISTORY (SUMMARY)

AUTHORIZATION TO RELEASE INFORMATION

I hereby authorize the release of the medical and background information described below from the custodians of the records identified herein to the recipient(s) named in this form for the purposes specified. This authorization includes the disclosure of information created before the date of this authorization unless otherwise limited below.

Treatment   Payment   Care coordination   Employment/Volunteer screening   Legal proceedings  

Full medical record   Billing and financial records   Laboratory reports   Radiology and imaging reports   Immunization records  

Mental health records   Substance abuse treatment records   HIV-related information  

RECIPIENT(S) OF INFORMATION

AUTHORIZATION PERIOD & REVOCATION

This authorization is effective as of:    and will expire on: unless earlier revoked in writing.

I understand that I may revoke this authorization at any time by delivering a written notice of revocation to the custodian of the records identified above. Revocation will not affect disclosures already made in reliance on this authorization prior to the custodian's receipt of the written revocation.

IMPORTANT NOTICES AND CONSENT

I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by privacy laws. I acknowledge that certain records (such as psychotherapy notes, substance use treatment records, or HIV-related records) may require additional authorization under applicable law. If such information is included, I consent specifically to its release as indicated above.

I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on signing this authorization except where allowed by applicable law. I further understand I have the right to inspect or copy the information to be disclosed, and that a copy of this authorization is as valid as the original.

By signing below I certify that I am the patient or I am authorized to execute this authorization on behalf of the patient and that the information provided on this form is true and correct to the best of my knowledge.

I acknowledge receipt of the entity's Notice of Privacy Practices.

SIGNATURE

By signing below, I authorize the release of the records as described above and attest that I have the authority to make this designation.

Signing as guardian or authorized representative? Yes

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