Release of Information Form

This form is secure, and all submissions are fully encrypted to protect your personal information.

Patient's Name*

First NameLast Name

Birth Date*

MonthDayYear

Last 4 SSN*

I authorize the following provider to release my medical records*

Type of Information to be Released*

History of Information to be released

Purpose of Information of Release

My Rights

I understand that I have the right to revoke this authorization, in writing, at any time, except where uses or disclosures have already been made based upon my original permission. I may not be able to revoke this authorization if its purpose was to obtain insurance. In order to revoke this authorization, I must do so in writing and send it to the appropriate disclosing party.

I understand that uses and disclosures already made based upon my original permission cannot be taken back.

I understand that it is possible that information used or disclosed with my permission may be redisclosed by the recipient and is no longer protected by the HIPAA Privacy Standards.

I understand that treatment by any party may not be conditioned upon my signing of this authorization (unless treatment is sought only to create health information for a third party or to take part in a research study) and that I may have the right to refuse to sign this authorization.

A copy of this authorization is as valid as the original.

Signature*

Date

HIPAA AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION