Healthcare PMR Document

PATIENT MEDICAL RECORDS RELEASE (PMR)

Patient Name:   Date of Birth:   Medical Record No.:

Contact & Demographic Information

Insurance Information

Brief Medical Summary (for identification)

Authorization to Release Medical Information

I authorize the release of my protected health information from: to:

Recipient Address / Contact:

Entire Medical Record (including all notes and charts)
Discharge Summaries / Consultation Notes
Laboratory and Pathology Reports
Imaging Reports and Films (X‑ray, CT, MRI)
Operative and Procedure Reports
Medication Administration Records and Prescriptions
Mental Health Records (psychotherapy notes require explicit authorization below)
Substance Abuse Treatment Records (if applicable)
HIV/AIDS Related Records (if applicable)

Specific date range for records: From to . If no dates provided, release may include all records up to the date of signature.

Purpose of Disclosure

Conditions, Fees, and Redisclosure

I understand that: (a) the information released may include sensitive information, including alcohol/drug treatment, mental health treatment, and HIV/AIDS status where applicable only if I have expressly authorized such release; (b) the recipient may redisclose information and federal privacy protections may no longer apply; and (c) a reasonable fee may be charged for copying and postage in accordance with facility policy.

I understand that treatment, payment, enrollment or eligibility for benefits cannot be conditioned on signing this authorization except where allowed by law. I may revoke this authorization in writing at any time by submitting a written revocation to the releasing facility, except to the extent that action has already been taken in reliance on this authorization.

HIPAA Privacy Acknowledgment & Patient Rights

By signing below I acknowledge that I have read and understand this authorization. I understand my rights under applicable privacy laws, including the right to receive a copy of this authorization upon request, the right to revoke this authorization as described above, and the right to refuse to sign this authorization.

Do you want a copy of the records released sent to you as well?   Yes    No

Certification

I certify that I am the patient or the patient's authorized representative and have the authority to execute this authorization. I understand the nature of this authorization and that the facility, provider, or custodian of records will comply with its terms in releasing the requested information.

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