Healthcare Release of Documents

HEALTHCARE RELEASE OF DOCUMENTS

Patient Name:   Date of Birth:   Medical Record Number:

1. Authorizing Provider / Facility

2. Recipient of Records

3. Records To Be Released

I authorize the release of the following records (check all applicable):

Medical history and clinical notes
Laboratory and pathology reports
Radiology / imaging reports and films
Billing and payment records
Mental health records (excluding psychotherapy notes)
Psychotherapy notes (special authorization required)
Records related to substance use disorder treatment (may be protected)
HIV/AIDS testing and related records (may be protected)

Date Range for Records: From to

4. Purpose of Disclosure

Continuing care / referral
Insurance claim / benefits determination
Legal / third party request
Personal use

5. Method of Disclosure

Mail
Fax   Fax number:
Secure Email / Electronic delivery   Email:
Patient or authorized representative pickup
Direct electronic portal transfer

6. Authorization & Legal Acknowledgments

I authorize the above named provider/facility to disclose my protected health information (PHI) as specified in this form. I understand that information to be released may include medical records, billing information, treatment summaries, laboratory and imaging reports, and other information described above. I expressly authorize the release of records that may indicate the diagnosis or treatment of behavioral health conditions, HIV/AIDS status, and substance use disorder treatment, if such records are indicated above.

I understand that psychotherapy notes (if any) are treated separately and will not be released without my separate, specific authorization, except as permitted by law. I acknowledge that the recipient may redisclose information and that once disclosed, the information may no longer be protected by federal privacy rules; however, certain categories of information may remain protected by additional state or federal law.

I may revoke this authorization at any time by delivering a written revocation to the health information management department of the releasing provider/facility. The revocation will not apply to information already released in reliance on this authorization prior to receipt of the revocation. This authorization will expire on the earlier of the date specified below in the Expiration section or one year from the date of my signature, unless a different expiration is specified.

I understand that treatment, payment, enrollment, or eligibility for benefits may not be conditioned on my signing this authorization except where allowed by law. I understand that a reasonable fee may be charged for copying and mailing records as permitted by law, and that I will be provided an estimate if requested prior to release.

By signing below I certify that I am the patient or am authorized to act on behalf of the patient as the patient’s legal representative. I certify that I have read and understand the terms of this authorization and that the information provided on this form is true and correct.

7. Contact for Questions

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