Healthcare Release of Medical Record

Healthcare Release of Medical Record

Patient Information

Date of Birth:    Gender:

Phone:    Email:

Insurance Information

Policy Number:    Group Number:

Recipient of Records

Recipient Phone:    Fax:

Records To Be Released

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

All medical records

Office visits / progress notes

Operative reports / procedure notes

Laboratory reports

Imaging / radiology reports

Billing and insurance records

Sensitive information (select each you specifically authorize):

HIV/AIDS test results and related treatment

Psychotherapy notes (separate specific authorization required)

Mental health records (excluding psychotherapy notes)

Substance use disorder treatment records

Date range for records to be released: From to

Purpose of Disclosure

Purpose (select one or more):

Continuation of care / referral    Insurance claim / coverage

Legal representation    Personal use

Method of Disclosure

Mail    Pick up in person    Fax

Electronic transmission (unsecured email only if expressly authorized)

Authorization, Rights, and Limitations

By signing below I authorize the release of my protected health information as specified above. I understand that the information disclosed pursuant to this authorization may include records created by other providers and may include sensitive information if I have indicated consent for such categories.

I understand that I may revoke this authorization at any time by delivering a written revocation to the health information management department of the releasing provider, except to the extent that action has already been taken in reliance on this authorization. A revocation is not effective to the extent that others have relied on the information or if the authorization was obtained as a condition of obtaining insurance and the insurer has a legal right to the information.

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. This provider is not responsible for unauthorized redisclosure by the recipient.

I understand that the provider may impose a reasonable fee for copying and/or postage in accordance with applicable law, and that I may be required to prepay such charges.

Certification

I certify that I am the patient or I am authorized to act on behalf of the patient as the patient's personal representative. I understand that signing this form is voluntary. I acknowledge that the information provided on this form is accurate and complete to the best of my knowledge.

Additional Instructions or Limitations

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