Healthcare PDR Document

HEALTHCARE PDR DOCUMENT

This Patient Disclosure and Release (PDR) Document authorizes the disclosure of protected health information in accordance with applicable privacy laws. Patient Name: Date of Birth: Medical Record No.:

Patient Information

Insurance Information

Medical History (Summary)

Authorization for Release of Protected Health Information

I authorize the disclosure of my protected health information as described below to: Recipient Address:

Date range of records to be released: From To

Authorization Term, Revocation & Redisclosure

This authorization will expire on . If no date is provided, this authorization will expire 180 days from the date of signature below. I understand that I may revoke this authorization at any time by delivering a written revocation to the health information custodian, but that revocation will not affect disclosures already made in reliance on this authorization.

I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by law. I release the disclosing health care provider and its agents from liability for disclosures made pursuant to this authorization.

Fees, Restrictions and Special Instructions

I understand there may be reasonable fees for copying, postage, or retrieval of records as permitted by law. I understand the provider will not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this authorization, except as permitted by law.

Acknowledgment and Certification

By signing below I certify that I am the patient or am authorized to act on the patient's behalf. I have read and understand this authorization. I authorize release of the protected health information described above and acknowledge receipt of a copy of this form upon request.

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