Healthcare Medical Release Consent Form

Medical Release Consent Form

Patient Information

Patient Name:

Insurance Information

Authorization for Release of Medical Information

I hereby authorize the release of my protected health information as described below from the medical records maintained by this provider to:

Recipient Name:

Purpose of Disclosure (select all that apply)

Continuing care/transfer of care
Billing/insurance claim
Legal
Personal
Other:

Records to be Released (select appropriate items)

All medical records
Discharge summaries/operative reports
Laboratory results
Radiology images/reports
Consultation notes
Mental health/psychotherapy notes (if checked, initial to authorize):
HIV-related information (if checked, initial to authorize):
Substance use disorder treatment records (if checked, initial to authorize):
Genetic testing information (if checked, initial to authorize):

Dates of service to be released: From through

Authorization Terms and Acknowledgments

I authorize the release of the records as described above. I understand that the information disclosed under this authorization may include sensitive information and that I have specifically authorized the release of any sensitive categories I selected above. I understand that this authorization is voluntary and that treatment, payment, enrollment, or eligibility for benefits is not conditioned upon signing this form except where allowed by law.

I understand that once information is disclosed to the recipient, it may be subject to redisclosure and no longer protected by federal privacy regulations. I release the disclosing provider and its staff from civil or criminal liability that may arise from disclosures made pursuant to this authorization, to the extent permitted by law.

I understand that I may revoke this authorization in writing at any time by submitting a written revocation to the medical records department, except to the extent that action has already been taken in reliance on this authorization. Revocation will not affect disclosures made prior to receipt of the revocation. Unless otherwise revoked, this authorization will expire on:

Fees: I understand that a reasonable copy fee may be charged for preparing copies of records and that payment may be required prior to release unless otherwise agreed.

I acknowledge that I have the right to request a copy of this authorization. A copy or photocopy of this authorization shall be as valid as the original.

Patient Rights

By signing below, I certify that I am the patient or am authorized to act on behalf of the patient and that the information on this form is correct. If signed by a personal representative, documentation of authority (such as power of attorney or guardianship documentation) may be required.

Yes No

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