Patient Records Release

Patient Records Release

Recitals

WHEREAS, Patient Name: (the "Patient") is a recipient of health care services;

WHEREAS, Patient Date of Birth: and Patient ID Number: ; and

WHEREAS, the Patient hereby authorizes the disclosure of certain protected health information as set forth below.

Authorization to Disclose

I authorize the following Covered Entity or Provider to disclose records:

Recipient of Records

I authorize the release of records to:

Scope of Release

The following records and information (select and / or describe) are authorized for release:

Medical history and progress notes

Laboratory and diagnostic reports

Radiology images and reports

Billing and payment records

Other (specify in detail below)

From:    To:

Method of Release

Records may be released by the following method(s). Check all that apply:

U.S. Mail or Courier

Fax

Secure Electronic Transmission

In-person Pickup

Fees and Payment

The Patient understands and agrees that reasonable fees may be charged for copying, reproduction, postage, and administrative costs. Payment is due at time of request unless other arrangements are made.

Payment Responsibility: Patient Recipient Provider

Term, Expiration, and Revocation

This authorization is effective from: until: , or until revoked in writing by the Patient, whichever occurs first.

Revocation must be submitted in writing to the releasing Provider. Revocation will not affect disclosures made prior to receipt of the written revocation.

Redisclosure and Confidentiality

The recipient of the disclosed information may not re-disclose health information except as permitted by law. Once disclosed, the information may no longer be protected and could be subject to re-disclosure. The Provider will make reasonable efforts to limit the information disclosed to that which is necessary to achieve the stated purpose.

Sensitive Information

Certain categories of information require specific authorization. By indicating below, the Patient authorizes release of the following sensitive information (if applicable).

Mental health and psychotherapy notes

Substance abuse treatment records

HIV/AIDS-related records

Acknowledgements and Certifications

By signing below, the Patient or the Patient's authorized representative certifies that they have the authority to request disclosure of the records described above, that they have read and understand this authorization, and that they understand the rights and limits described herein.

Governing Law and Entire Agreement

This authorization shall be governed by the laws of the state in which the Provider maintains the records. This document contains the entire agreement between the parties concerning this authorization; any amendment must be made in writing and signed by the Patient or authorized representative and the Provider.

Patient or Authorized Representative Information

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