Healthcare Release Agreement

Healthcare Release Agreement

Patient Information

Date of Birth:    Gender:

Insurance Information

Medical History (Brief)

Authorization to Release Protected Health Information (PHI)

I, the undersigned Patient, authorize the release of my protected health information as described below. Patient Name:

Purpose of Disclosure:

Information to be released (check all that apply):

Medical progress notes, diagnosis, treatment records
Mental health / psychotherapy notes (explicit consent required)
Substance use treatment records (explicit consent required)
HIV/AIDS-related test results and records (explicit consent required)
Billing and insurance records
Other (specify):

This authorization includes the disclosure of any and all medical records and information made or received by the releasing provider concerning my condition and care, unless excluded above.

This authorization is effective immediately and shall expire on: . If no date is provided, this authorization will expire one year from the date signed unless otherwise required by applicable law.

Conditions, Rights, and Acknowledgements

I understand that I may revoke this authorization at any time by delivering a written notice of revocation to the releasing provider, 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 revocation.

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 privacy regulations. However, certain information released from mental health, substance use disorder, or HIV records may remain subject to additional protections under applicable law; the recipient is prohibited from further disclosure except as permitted by law.

I understand that treatment, payment, enrollment, or eligibility for benefits may not be conditioned on my signing this authorization, except where allowed by law for research-related care or where the provision of healthcare is solely for the purpose of creating protected health information for disclosure to a third party.

I acknowledge that I may be charged reasonable fees for copying and postage in accordance with applicable law. I authorize release of information necessary to process claims and understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient.

By signing below I certify that I have read and understand this authorization and that the information I have provided on this form is accurate to the best of my knowledge.

HIPAA Privacy Acknowledgment: I acknowledge that I have been informed of my rights under the federal privacy regulations and applicable state law regarding my protected health information.

If signed by a personal representative, legal guardian, or other authorized person, certify authority to act on behalf of the patient and describe relationship below.

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