Authorization for Release of Protected Health Information Form

Authorization for Release of Protected Health Information Form
Date

MonthDayYear
Date
Name of Patient

First NameLast Name
Name of Releasee / Personal Information Controller
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
I, the above-named Releasor, hereby authorize the release of:
Consent to release of health information:

All my health informationMy health information relating to
Health information
Please provide details what kind of health information shall be shared or disclosed and/or the date period
This authorization shall remain effective from the time of execution of this document until:
Date or Event
Provide a date, instance, or event that this authorization shall cease to be effective
By signing this document, I hereby declare that I understand and acknowledge that I am giving authorization to the use and/or disclosure of my protected health information as described and for the purpose specified above.

I am signing this authorization voluntarily. I understand that I have the right to withdraw my permission or withdraw my authorization at any time by writing. In case I withdraw my authorization, I understand that any benefits, treatment, or eligibility shall not be affected.

Further, I understand that this authorization may not further be used by the person or entity to whom my medical records are to be disclosed, to use or disclose the said information to another unless otherwise permitted in writing or unless such intended disclosure is required or permitted by law.
Name of Patient/Representative

First NameLast Name
Signature

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Date Signed

MonthDayYear
Date
Relation to Patient (if Releasor is not the Patient)
Upload Proof of Identity

Cancelof
Type of Identification
Identification Number
Should be Empty: