Medical Release Authorization Form

Medical Release Authorization Form

Patient Name:    Date of Birth:

Provider/Facility Releasing Records:

Recipient Name/Organization:

RECITALS

WHEREAS, Patient identified above is a current or former recipient of health care services from the Provider/Facility releasing records; and

WHEREAS, Patient hereby requests and authorizes Provider/Facility to disclose certain protected health information to the Recipient named above for the purposes set forth below; and

WHEREAS, the parties acknowledge that this Authorization is made voluntarily and that certain conditions and limitations apply as set forth herein.

NOW, THEREFORE, in consideration of the mutual promises and covenants contained herein, the parties agree as follows:

1. AUTHORIZATION TO RELEASE

Patient authorizes Provider/Facility to release to Recipient the following protected health information:

Time period of records to be disclosed (if applicable):

2. PURPOSE OF DISCLOSURE

Purpose for which disclosure is authorized (check all that apply and specify if Other):

Continuing medical care   Insurance/claims processing   Legal matter   Personal use

3. METHOD AND FORMAT OF DISCLOSURE

Records may be disclosed in the following format(s): Electronic (secure transmission)    Paper copy    CD/DVD

If electronic, deliver to (email address or secure portal identifier):

4. LIMITATIONS, REDISCLOSURE AND LIABILITY

Patient understands that information disclosed under this Authorization may include sensitive categories of information, which may include mental health, substance use treatment, HIV/AIDS-related information, genetic testing, and other protected categories where applicable. Where required by law, a separate authorization is required for these categories; by signing below Patient specifically authorizes release of such information if indicated above.

Recipient is hereby notified that once information is disclosed, federal and state law may not protect the information from further redisclosure by the Recipient. Provider/Facility and its agents are not liable for any disclosures made by Recipient after release pursuant to this Authorization.

5. EXPIRATION AND REVOCATION

This Authorization shall remain in effect until: . Patient may revoke this Authorization at any time by providing a written revocation to Provider/Facility, except to the extent Provider/Facility has already acted in reliance on this Authorization. Revocation is ineffective to the extent that action has been taken in reliance on this Authorization.

6. EFFECT ON TREATMENT AND PAYMENT

Patient understands that refusal to sign this Authorization will not affect Patient's ability to obtain treatment, payment, enrollment, or eligibility for benefits, unless the disclosure is necessary to carry out treatment or apply for health plan coverage, and the Provider/Facility has informed Patient otherwise.

7. FEES

Provider/Facility may charge a reasonable, cost-based fee for copying and postage in accordance with applicable law. Patient agrees to pay applicable fees: I agree to pay reasonable copying/processing fees.

8. NOTICES

Notices, including any revocation, must be delivered in writing to the Provider/Facility at the address on file and to the Recipient at the address above. For purposes of this Authorization, written notice is effective upon receipt.

9. AMENDMENT, WAIVER, COUNTERPARTS, SEVERABILITY AND GOVERNING LAW

This Authorization may be amended only by a written instrument signed by Patient and Provider/Facility. No waiver of any provision shall be effective unless in writing signed by the party waiving compliance. This Authorization may be executed in counterparts, each of which is deemed an original and all of which together constitute one instrument. If any provision is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

This Authorization shall be governed by and construed in accordance with the laws of the state in which the Provider/Facility is located, without regard to its conflicts of law principles.

10. ENTIRE AGREEMENT

This Authorization constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior agreements, whether written or oral, relating to the same.

ACKNOWLEDGMENT AND PATIENT CERTIFICATION

I certify that I have read and understand this Authorization; that the information provided is complete and accurate; that I am signing voluntarily; and that I have been provided the opportunity to ask questions. I understand that I have the right to receive a copy of this Authorization upon request.

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