Healthcare Medical Release Form

HEALTHCARE MEDICAL RELEASE FORM

Patient Information

Date of Birth:    Gender:    Medical Record / Patient ID:

Primary Phone:    Alternate Phone:    Email:

Relationship:    Phone:

Insurance Information

Policy / ID Number:    Group Number:    Subscriber Name:

Medical History (Brief)

Authorization to Release / Obtain Records

I authorize the following party to: located at

To: Release Records To

Continuity of care    Insurance / Payment    Legal    Personal use    Other:

All medical records (including mental health and substance use treatment)   
Laboratory results    Imaging / Radiology reports    Clinic / progress notes   
Billing and insurance records    Mental health records (psychotherapy notes excluded)    Substance use disorder treatment records   
HIV test results / status    Genetic testing results   
Other:

I understand that certain types of information are subject to additional protections under applicable law. If I am authorizing release of mental health notes, substance use disorder treatment records, HIV-related information, or genetic test results, I acknowledge that I have explicitly identified those categories above. Initial to authorize release of specially protected categories: Mental Health Initials:    Substance Use Initials:    HIV Initials:

Authorization Period and Revocation

This authorization is effective from: and expires on: unless earlier revoked in writing.

I understand that I may revoke this authorization at any time by providing a written notice to the releasing provider, except to the extent that action has already been taken in reliance on this authorization. Revocation is not effective to the extent that others have relied upon or acted in reliance on this authorization.

Redisclosure and Liability

I understand that once my protected health information is disclosed pursuant to this authorization, the recipient may re-disclose the information and that the information may no longer be protected by federal privacy regulations. The releasing provider is not responsible for the actions of the recipient after disclosures are made in accordance with this authorization.

Conditions and Acknowledgments

I acknowledge that I have the right to refuse to sign this form and that my refusal will not affect my ability to obtain treatment, payment, enrollment, or eligibility for benefits, except where allowed by law. I certify that I am the patient or a person authorized to act on behalf of the patient and that the information provided on this form is true and correct to the best of my knowledge.

Patient Certification

By signing below I authorize the use or disclosure of the protected health information described above. I understand the nature of this authorization, the limits of confidentiality, and the potential for redisclosure. I acknowledge that a copy or facsimile of this authorization is as valid as the original.

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