Authorization to Disclose Health Information

Patient Information

Name:

DOB: SSN (last 4):

Phone: Email:

Address:

Facility Name:

Address:

Phone: Fax:

Release Authorization

Records Requested (check all that apply)

Complete Medical Record (all records, labs, radiology)

Mental Health/Psychiatric records

Hospital Records (ER, discharge, operative summaries)

Substance Abuse Treatment records

Outpatient/Clinic Records

HIV/AIDS testing or treatment records

Laboratory Results

STD-related records

Radiology/Imaging (X-rays, MRI, CT scans)

Genetic Testing results

Pharmacy Records (medication history)

Photos/Images/Videos

Billing Records

Immunization Records

Your Rights and Important Information

I understand and acknowledge:

I may revoke this authorization in writing at any time, but revocation will not apply to information already released.
The healthcare provider may not condition treatment, payment, or enrollment on whether I sign this authorization.
Information disclosed may be subject to re-disclosure by the recipient and may no longer be protected by federal or state privacy laws.
I have the right to inspect and receive a copy of the information disclosed under this authorization.
Signing this authorization is voluntary. I may be charged a reasonable fee for copying and mailing in accordance with state and federal law.

One year from signature date

Specific date:

Upon event:

Signature of Patient or Authorized Representative

Printed Name

Date

If representative, relationship: