Healthcare Release of Medical Records

Release of Medical Records Authorization

Patient Name:

Date of Birth:

Emergency Contact

Record Release Instructions

I authorize the release of my protected health information as described below. This authorization applies to records created by the releasing facility and those sent to the releasing facility by other providers unless otherwise limited below.

Records to Be Released

Entire medical record, including history, clinic notes, test results, billing information and correspondence

Only the following specific records or date range (describe):

If limited by date, From:   To:

Sensitive Information

Some records may contain sensitive information. By initialing below you specifically authorize release of the following categories:

HIV-related testing, diagnosis or treatment

Mental health records (excluding psychotherapy notes)

Substance use disorder treatment records

Psychotherapy notes (separate written authorization may be required in addition to this form)

Delivery Method

Mail

Fax — Fax number:

Secure Email — Email address:

Pick-up by individual named below — Name:

Electronic portal / secure messaging

Authorization Term, Revocation, and Fees

This authorization will expire on:

I understand that I may revoke this authorization at any time by providing written notice to the releasing provider, except to the extent the provider has acted in reliance on this authorization. Revocation will not affect disclosures made prior to receipt of revocation.

I understand that a fee may be charged for copying and postage as permitted by law. Payment of fees is the responsibility of the requestor unless otherwise agreed in writing.

Redisclosure and Rights

I understand that once my information is disclosed pursuant to this authorization, the recipient may re-disclose it and the information may no longer be protected by federal privacy regulations. Some state laws may provide additional protections for certain types of information.

I understand that signing this form is voluntary and that my treatment, payment, enrollment or eligibility for benefits will not be conditioned on my signing this authorization unless the disclosure is for eligibility or claims payment related to research or where allowed by law.

Acknowledgements

I acknowledge that I have read and understand this authorization and have received a copy of it upon request.

I understand my right to revoke this authorization in writing as described above.

Medical History (Optional but helpful)

Certification

By signing below I certify that I am either the patient named above or the patient's authorized legal representative. I authorize the providers listed to disclose my protected health information as specified in this authorization. I understand the statements above and consent to the release as indicated.

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