Healthcare Production Approval Form

HEALTHCARE PRODUCTION APPROVAL FORM

This Healthcare Production Approval Form authorizes the release, copying and production of the patient’s protected health information (PHI) as specified below. By signing, the patient or authorized representative grants the identified health care provider permission to produce and transmit records, images, reports, billing information and other specified documents to the designated recipient for the stated purpose. This authorization is voluntary, may be revoked in writing as provided below, and complies with applicable privacy law requirements.

Patient Information

Insurance Information

Medical History Summary (Optional)

Records Requested / Description of Production

Date Range for Records: From to .

Please select the specific items to be produced:

Preferred format for production:

Purpose of Disclosure

Fees, Charges and Acknowledgements

The provider may impose reasonable fees for copying, labor and postage in accordance with applicable law. Electronic transmission to an unsecured email address is at the patient’s risk. By checking the box below the patient acknowledges responsibility for applicable fees and accepts conditions of transmission.

Authorization, Revocation and Expiration

I hereby authorize the above-named health care provider to produce and disclose the specified protected health information to the recipient identified in this form. I understand that I may revoke this authorization at any time by providing written notice to the health care provider, except to the extent that action has already been taken in reliance on this authorization. This authorization expires on or upon completion of the request, whichever occurs first.

I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state privacy laws. I understand that treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this authorization except where allowed by law.

Special Categories of Information

If you wish to authorize production of certain sensitive records, please indicate below by initialing the applicable category. Separate explicit authorization may be required under applicable law for these categories.

Certification and Signature

I certify that I am the subject of the information or I am authorized to act on behalf of the subject (as parent, legal guardian, or personal representative). I certify that the information I have provided is true and accurate to the best of my knowledge and that this authorization is given voluntarily for the purposes stated herein.

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