HIPAA Authorization Form

HIPAA Medical Records Release Form
Patient Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Date today

Month Day Year
Date
Allowed Purpose of Disclosure of Information
For medical necessity determination for health insurance claims. Indicate the purpose of disclosure (e.g. For research, for sponsorships, further development of study)
Physician/Medical Facility Allowed to Disclose Information *
Phone Number

Area Code Phone Number
Type of Medical Information to be disclosed *

All Medical Records

I understand I may revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to AOP. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire 5 years from the date signed. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or obtain a copy of the information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential for unauthorized redisclosure and the information may not be protected by federal confidentiality rules. If I have questions about the disclosure of my health information, I can contact the authorized individual or organization making the disclosure.
I have read the above foregoing Authorization for Release of Information and do hereby acknowledge that I am familiar with and fully understand the terms and conditions of this authorization.
I hereby authorize the use and/or disclosure of my protected health information as described above.
Signature of Patient / Subject

Clear
Date Signed

Month Day Year
Date

I understand I may revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to AOP. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire 5 years from the date signed. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or obtain a copy of the information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential for unauthorized redisclosure and the information may not be protected by federal confidentiality rules. If I have questions about the disclosure of my health information, I can contact the authorized individual or organization making the disclosure.
I have read the above foregoing Authorization for Release of Information and do hereby acknowledge that I am familiar with and fully understand the terms and conditions of this authorization.
I hereby authorize the use and/or disclosure of my protected health information as described above.
Parent or Legally Authorized Representative In case the subject is beyond the legal age of consent:
Name of Parent or Guardian

First Name Last Name
Relationship to Subject
Signature of Parent / Guardian

Clear
Date Signed

Month Day Year
Date
Should be Empty:

HIPAA Medical Records Release Form