Healthcare Data Release Agreement

HEALTHCARE DATA RELEASE AGREEMENT

Patient Name:    Date of Birth:    Medical Record Number:

Patient Information

Male    Female    Other    Prefer not to say

Insurance Information

Medical History (Relevant)

Release Details

Recipient Information

Types of Information To Be Released

Medical records (office notes, progress notes)
Laboratory results
Imaging reports and images (X-ray, MRI, CT)
Behavioral and mental health records
Billing and claims information
Other (specify)

Date range to be released: From to

Purpose of Disclosure

Continuity of care / treatment
Research (with required IRB approval)
Insurance / claim adjudication
Legal / court proceedings
Personal use (patient copy)
Other (specify)

Authorization and Terms

I authorize the use and disclosure of my protected health information as described in this Healthcare Data Release Agreement. This authorization permits the release of the categories of information and date ranges checked above to the recipient identified in this form. The disclosure authorized herein may include information related to substance use disorder treatment, mental health treatment, infectious disease, and other sensitive health matters unless specifically excluded below.

By signing this form I understand that: (1) my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on signing this authorization; (2) I may inspect and copy the health information to be used or disclosed; and (3) I may revoke this authorization at any time by delivering written notice to the provider's Privacy Officer, except to the extent that the action has already been taken in reliance on this authorization.

I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state privacy regulations. The provider is released from all legal responsibility and liability that may arise from the release of information as authorized herein.

I authorize the release of the records indicated above and request that copies be provided to the recipient named herein. I certify that the information I have provided on this form is true and correct to the best of my knowledge.

Fees and Limits

The provider may charge a reasonable, cost-based fee for preparing and delivering copies of medical records as permitted by applicable law. Fees must be paid prior to release of records unless otherwise required by law. This authorization does not obligate the provider to create records or produce summaries not already maintained in the medical record.

Expiration and Revocation

This authorization will expire on unless revoked earlier in writing.   No expiration (if allowed by law)

Special Authorizations (if applicable)

If you DO NOT want the following information released, check to exclude each item. Unless excluded, these categories will be released when included in the scope selected above.

Exclude substance use disorder treatment records
Exclude psychotherapy notes
Exclude HIV-related information

Acknowledgment

I acknowledge that I have read and understand this authorization and that I am the patient or I am authorized to sign on behalf of the patient as the patient's personal representative. I understand my rights regarding the revocation and expiration of this authorization and the possible redisclosure of my health information by the recipient.

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