Healthcare Medical Info Release Form

HEALTHCARE MEDICAL INFORMATION RELEASE FORM

Purpose: Authorization for the disclosure of protected health information from the records of the individual named below. This form permits the release, inspection, and copying of medical records as specified herein. Information released pursuant to this authorization may include information protected by state or federal law, including sensitive categories identified below only if specifically authorized by the patient.

Patient Information

Date of Birth:    Gender: Male Female Other

Emergency / Alternate Contact

Relationship:    Phone:

Insurance Information (if records relate to insurance claims)

Policy Number:    Group Number:

Entities Authorized to Release / Receive Information

Purpose and Scope of Disclosure

Purpose of disclosure (select all that apply):
Continuing care / referral   Insurance claim or payment   Legal representation   Personal use   Other:

Records To Be Released

I authorize release of the following (check all that apply):
Complete medical record   History & physical   Laboratory reports   Radiology / imaging   Operative reports   Billing and claims records   Immunization records   Other:

Sensitive information: Disclosure of certain information requires explicit authorization. If you authorize release of any item below, please place your initials in the corresponding field.

Mental health / psychotherapy notes — Initials:
Substance use disorder treatment records — Initials:
HIV / AIDS-related information — Initials:

Time Period

Release records for the period from through . If no period is specified, disclosures may include the entire medical record.

Method of Disclosure and Fees

Provide records by (select all that apply):
Mail physical copies   Fax   Secure electronic portal   Unencrypted email (consent required): Initials:

I understand that fees for copying and postage may apply and will be charged in accordance with the releasing provider's fees and applicable law. I authorize payment of copying fees to the releasing facility when required.

Expiration and Right to Revoke

This authorization will expire on , or upon the following event: , whichever occurs first. I understand I may revoke this authorization at any time by providing a written revocation to the releasing facility, except to the extent that action has already been taken in reliance on this authorization, and except as prohibited by law.

Redisclosure / Notice

I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer protected by federal privacy regulations. Certain information may remain protected from redisclosure under state law; however, the releasing provider is not responsible for subsequent redisclosure by the recipient.

Revocation and Special Notices

Revocation must be made in writing and delivered to the medical records department of the releasing provider. Revocation will not affect disclosures made prior to receipt of the written revocation. This authorization is voluntary and treatment, payment, enrollment, or eligibility for benefits will not be conditioned on signing this form, except where allowed by law.

Acknowledgements

By signing below I acknowledge that I have read and understand this form, that the information to be released may include sensitive health information only as specifically initialed above, and that I have received a copy of this authorization upon request.

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