Medical Release Form

MEDICAL RELEASE FORM

Patient Name:    Date of Birth:

Address:

Phone:    Email:

WHEREAS

WHEREAS, the Patient named above (hereinafter "Patient") seeks to authorize the disclosure of protected health information to a designated Recipient for the purpose described below; and

WHEREAS, the Recipient or Requesting Party requires specific medical records, documents, or other protected health information in order to provide care, continuity of services, insurance processing, legal review, or administrative purposes; and

WHEREAS, the Patient has the right to revoke this authorization in writing except to the extent that action has already been taken in reliance upon it; the parties therefore agree as set forth below.

RECIPIENT / REQUESTING PARTY

SCOPE OF RELEASE

The Patient hereby authorizes the release of the following records and information (check all that apply):

Medical history and office notes   Imaging/radiology reports   Laboratory test results  

Mental health records (may require additional authorization)   Substance abuse treatment records (may require special consent)   Other:

PAYMENT TERMS

Fees for retrieval, duplication, and processing of records shall be as stated below and are the responsibility of the unless otherwise agreed in writing.

Late Fee: In the event payment is not received when due, a late fee of may be applied to outstanding amounts, and collection costs will be charged to the responsible party.

TERM AND TERMINATION

This Authorization is effective as of the Start Date and shall expire on the End Date below, subject to earlier revocation as provided herein.

Start Date:    End Date:

Notice of intent to terminate or to revoke this Authorization must be provided in writing to the entity holding the requested records. Revocation will be effective upon receipt except to the extent the holder has relied upon this Authorization.

CONFIDENTIALITY AND LIMITATIONS

The Recipient shall use and disclose protected health information only for the purposes set forth in this Authorization. The Recipient shall implement reasonable administrative, technical, and physical safeguards to protect the confidentiality of disclosed information in accordance with applicable law.

The Patient understands that information disclosed pursuant to this Authorization may be subject to redisclosure by the Recipient and may no longer be protected by certain privacy protections; the Recipient is expressly directed not to further disclose sensitive categories of information without additional written authorization, except as required by law.

AUTHORIZATION AND CERTIFICATION

By signing below, the Patient certifies that they are the individual whose information is to be disclosed (or have the authority to act on behalf of such individual), that they authorize the release of the protected health information as described in this form, and that they understand the terms, risks, and conditions contained herein.

The Patient further acknowledges that refusal to sign this Authorization will not affect the Patient's ability to obtain treatment, payment, enrolment, or eligibility for benefits, except where services are conditioned on execution of the Authorization as permitted by law.

GOVERNING LAW

This Authorization shall be governed by and construed in accordance with the laws of the state of , without regard to its conflict of law principles.

ENTIRE AGREEMENT

This document constitutes the entire agreement and authorization between the Patient and the Recipient regarding the release of the Patient's protected health information and supersedes all prior oral or written authorizations on the same subject. Any amendment must be in writing and signed by the Patient.

EXPIRATION AND REVOCATION

Unless earlier revoked, this Authorization will expire on the Term End Date specified above. The Patient may revoke this Authorization at any time by delivering written notice to the records custodian; revocation will not apply to disclosures already made in reliance upon the Authorization.

ADDITIONAL ACKNOWLEDGMENTS

The Patient acknowledges receipt of a copy of this Authorization and understands that they are entitled to a copy after signing. The Patient further acknowledges that they may be charged reasonable fees for copies or retrieval as set forth above.

Sign Now