Healthcare Data Release Form

HEALTHCARE DATA RELEASE FORM

Patient Name:     Date of Birth:

Recipient of Protected Health Information

Release To (Name of person or organization):

Purpose of Disclosure

The information may be disclosed for the following purpose(s):

Continuity of care / ongoing treatment
Insurance claim / benefits coordination
Legal / court-related matters
Personal use / at patient request
Research (if applicable and approved)
Other:

Information to Be Released

Check only those items to be released. If none are checked, only the minimum necessary information will be disclosed.

Complete medical record, including clinic notes and correspondence
Discharge summaries and hospitalization records
Laboratory results and pathology reports
Imaging reports and images (X-ray, MRI, CT)
Medication records and prescription history
Billing and insurance information
Problem list, diagnoses, and treatment plan
Operative reports and anesthesia records
Mental health/psychiatric records (explicit authorization required)
Substance use disorder treatment records (42 CFR Part 2 - explicit authorization required)
HIV-related information and test results (explicit authorization required)
Genetic testing results (if applicable)
Other specified records:

Time Period Covered

Release records from: to:     All past, present and future records related to care

Expiration and Revocation

This authorization will expire on: .

I understand that I may revoke this authorization at any time by providing written notice to the releasing health care provider, except to the extent that action has already been taken in reliance on this authorization. Revocation must include patient name, date of birth, and a clear statement of intent to revoke.

Conditions and Important Notices

I acknowledge that:

1. Treatment, payment, enrollment, or eligibility for benefits may not be conditioned on signing this authorization unless permitted by law.
2. Information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer protected by federal privacy rules; however, certain categories (substance use disorder, HIV, psychotherapy notes) may have legal protections that limit redisclosure.
3. I may be charged a reasonable fee for copying and mailing records, and fees will be provided upon request prior to release.
4. I have the right to inspect or receive a copy of the information disclosed under this authorization, as permitted by law.

Patient Verification

To assist with verification, provide one or more of the following identifiers.

Additional Instructions

By signing below I authorize the release of my protected health information as specified above. I certify that I am the patient or the patient's personal representative and have authority to sign on the patient's behalf.

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