Healthcare Release Order

HEALTHCARE RELEASE ORDER

Authorization for Release of Protected Health Information (PHI). Patient authorizes the release of the medical records and other protected health information described below to the designated Recipient for the stated Purpose. This authorization is voluntary and will remain in effect only as provided below.

Patient Information

Patient Name:

Month:   Day:   Year:

Provider / Facility Releasing Records

Recipient / To Whom Records Will Be Sent

Treatment   Payment/Claims   Legal   Insurance Eligibility   Research  
Other (specify):

Information To Be Released

I authorize release of:   All medical records from any date of service  
Specific records (select below or describe):

History & physical, progress notes, discharge summary  
Laboratory results   Imaging/radiology reports and films  
Operative reports   Billing and payment records   Immunization records  

From: Month: Day: Year:    To: Month: Day: Year:

The following categories require explicit authorization and may be subject to additional protections. Initial each box to authorize release:

HIV/AIDS-related information   Substance use disorder treatment records (42 CFR Part 2)  
Mental health/behavioral health records (excluding psychotherapy notes)   Psychotherapy notes (separate authorization required)  
Genetic testing/results  

Fees and Conditions

Fees may be charged for copying and postage as permitted by applicable law. By signing below, the patient or authorized representative agrees to pay reasonable costs for reproduction, preparation, and delivery of records unless waived. This authorization does not obligate the Provider to accept collect calls or to provide records without appropriate payment or verification of identity.

Expiration and Revocation

This authorization will expire on: Month: Day: Year:    OR upon occurrence of the following event:

The patient may revoke this authorization at any time by providing 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 in reliance on the authorization prior to receipt of the revocation.

Acknowledgements and Legal Notices

I understand that I may refuse to sign this authorization and that my refusal will not affect my ability to obtain treatment, payment, enrollment, or eligibility for benefits unless the provision of the requested information is specifically required for such purpose. I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations.

I certify that the information provided on this form is true and accurate to the best of my knowledge. I authorize the use and disclosure of my protected health information as described above.

HIPAA Acknowledgment

By signing, I acknowledge that I have been informed of my rights regarding protected health information and have been provided the applicable privacy practices notice. I understand how my information may be used or disclosed and acknowledge the potential for redisclosure by the recipient.

I acknowledge receipt of the applicable privacy practices notice.

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