Medical Records Release Form

MEDICAL RECORDS RELEASE AUTHORIZATION

WHEREAS

WHEREAS, Patient Name: is a patient of the Custodian of Records identified below; and

WHEREAS, the undersigned seeks to authorize the disclosure of protected health information as set forth in this authorization for the limited purposes described herein.

AUTHORIZATION

I hereby authorize the Custodian of Records named below to disclose the protected health information described in this form to the Recipient named below. This authorization is voluntary and is not a condition of treatment, payment, enrollment, or eligibility for benefits.

PATIENT / SUBJECT INFORMATION

CUSTODIAN / PROVIDER TO RELEASE RECORDS

RECIPIENT OF INFORMATION

PURPOSE OF DISCLOSURE

Purpose (check all that apply):

Treatment or continuity of care    Billing or claims    Insurance eligibility/claims    Legal    Personal use

DESCRIPTION OF INFORMATION TO BE RELEASED

The following information is authorized for release (check each applicable item). Specific sensitive categories below require explicit initials to confirm authorization for those categories.

Complete medical record (all available records)
Summary of care, history and physical, discharge summary
Laboratory results and pathology reports
Imaging studies and radiology reports
Billing records, itemized statements
Other records (describe below)

Sensitive categories (initial each line to authorize release of that category):

HIV-related information: Initials:    Mental health records (psychotherapy notes excluded): Initials:    Substance use disorder treatment records: Initials:

TIME PERIOD FOR RELEASE

Release records for treatment dates from through . If left blank, this authorization applies to records created within the past one year unless otherwise limited below.

FEES FOR COPY

I understand that reasonable, cost-based fees for copying and postage may be charged by the Custodian of Records. If I wish to limit fees, I request a maximum charge of $.

REVOCATION

I understand that I may revoke this authorization at any time by submitting a written revocation to the Custodian of Records, except to the extent that action has already been taken in reliance on this authorization. Revocation is effective upon receipt by the Custodian unless otherwise specified below.

EXPIRATION

This authorization will expire on: . If no date is provided, the authorization will expire one year from the date of signature unless otherwise prohibited by law.

REDISCLOSURE

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. The Custodian will not control redisclosure by the Recipient except where prohibited by law.

RIGHT TO INSPECT

I understand that I have the right to inspect or receive a copy of the health information described in this authorization, subject to applicable law and reasonable fees.

CONFIDENTIALITY & LIMITATIONS

The Custodian shall release only the information expressly authorized herein. The Custodian shall take commercially reasonable steps to protect the confidentiality of disclosed records consistent with applicable law. This authorization does not authorize release of psychotherapy notes unless explicitly checked and initialed where required by law.

GOVERNING LAW

This authorization shall be governed by and construed in accordance with the laws of the state where the Custodian maintains the records, to the extent not preempted by federal law.

ENTIRE AGREEMENT

This document constitutes the entire agreement between the parties regarding the authorization to disclose the specified health information and supersedes all prior oral or written authorizations related to the same subject matter.

ACKNOWLEDGMENT AND SIGNATURE

By signing below, I certify that I am the patient or am authorized to act on behalf of the patient and that I have the authority to execute this authorization. I understand the contents of this form and acknowledge receipt of a copy of this authorization upon request.

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