Healthcare Disclosure Release

Healthcare Disclosure Release

Patient Information

Patient Name:

Date of Birth: Gender:

Recipient(s) Authorized to Receive Information

List the individual(s) or organization(s) to which you authorize disclosure. Provide full name and contact information.

Description of Information to Be Disclosed

Select the specific records or types of information you authorize for disclosure. If left blank, the release will be interpreted as limited to the items checked below.

Full medical record, including history and physical

Office notes and clinical progress notes

Billing, claims, and payment information

Laboratory test reports and pathology

Radiology and imaging reports (x-ray, MRI, CT)

Mental health notes and psychotherapy records

Substance use disorder treatment records

HIV/AIDS-related information and test results

Genetic testing information

Purpose of Disclosure

The information will be used for the following purposes. Select all that apply.

Continuity of care / coordination of treatment

Insurance claim, benefits, or eligibility

Legal matter or third-party representation

Personal use by patient or patient representative

Authorization Terms and Acknowledgments

I authorize the release of the medical information described above to the designated recipient(s). This authorization is limited to the specific information checked above and does not permit release of any other information except as expressly stated.

I understand that I may revoke this authorization at any time by providing a written notice of revocation to the health care provider, except to the extent that action has already been taken in reliance on this authorization. Revocation will not affect disclosures already made in response to this authorization prior to receipt of the revocation.

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 federal or state privacy laws. If I specifically authorize disclosure of treatment for mental health, substance use disorder, or HIV-related information, I acknowledge that additional protections may apply and that redisclosure may be further restricted by law.

I understand that the provider may charge a reasonable, cost-based fee for copying and preparing records for release. I have the right to inspect or copy the protected health information to be disclosed as provided by law.

Expiration: This authorization will expire on or upon the following event:

HIPAA Acknowledgment

By signing below I acknowledge that I have read and understand this authorization to disclose protected health information. I understand that signing this form is voluntary and that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned upon signing this authorization except where allowed by law.

I understand that I am entitled to receive a copy of this signed authorization upon request.

Signature and Certification

I certify that I am the patient or am authorized to act on behalf of the patient. I certify that the information provided on this form is true and correct and that I have the authority to request the disclosure described herein.

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