Healthcare Duplicate Information Release

Healthcare Duplicate Information Release

Patient Information

Patient Name:

Date of Birth:    Gender:

Insurance Information (if applicable)

Recipient / Destination for Duplicate Information

Relationship to Patient:

Records to Be Released

I authorize release of the following duplicate information (check all that apply):

  Entire medical record (from all dates)

  Laboratory and pathology reports

  Imaging studies and reports

  Operative and procedure reports

  Billing and account records

  Other:

From:    To:

Method of Duplicate Delivery

Please select preferred format(s):

  Paper copies

  CD / physical media

  Electronic file transfer (encrypted)

  Fax (may be less secure)    Fax number:

Purpose & Limitations

Purpose of disclosure:

I understand that the duplicate information provided pursuant to this authorization may include sensitive information such as mental health treatment, HIV/AIDS-related records, and substance use disorder treatment records unless I specifically mark otherwise below.

Exclude sensitive categories (check to exclude):

  Mental health treatment records

  HIV/AIDS-related records

  Substance use disorder treatment records

Fees, Expiration, and Revocation

I understand that reasonable fees may be charged for duplication, shipping, and handling. Payment is due prior to release unless otherwise agreed in writing.

This authorization will expire on: . If no date is provided, this authorization will expire ninety (90) days from the date signed.

I may revoke this authorization at any time by providing a written revocation to the releasing facility; however, revocation will not affect actions taken in reliance on this authorization prior to receipt of the revocation.

Redisclosure and Limits of Liability

I acknowledge that once my health information is released to the recipient named above, the information may be subject to redisclosure by that recipient and may no longer be protected by federal privacy regulations. The releasing health care provider is not responsible for unauthorized redisclosure by the recipient.

Verification of Identity

To protect privacy, I authorize the releasing facility to verify my identity or the identity of my authorized representative. Verification may include government-issued identification, signature comparison, or other reasonable means.

Medical History Summary (Optional)

Patient Certification and Authorization

By signing below, I certify that I am the patient identified on this form or the patient's duly authorized representative. I authorize the release of the duplicate information described above to the recipient named in this form. I understand the nature of this authorization, including my right to revoke it as described above, and I accept responsibility for any fees associated with duplication and delivery.

Relationship to patient (if signing as representative):

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