allenaim.com - Release of Records

Release of Records
All portions of this form must be completed to constitute a valid authorization for release of health information under the Health Insurance Portability and Accountability Act (HIPAA) privacy regulations. If any field is left blank, the authorization will be considered defective.
Patient's Name
Date of Birth

MonthDayYear
Date
Medical Recorder Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
I authorize the use and disclosure of health information about me as described below:
Facility Authorized to Release my Health Information
Agency or Individual(s) Authorized to Received my Health Information
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Health Information that may be used/disclosed is limited to the following:

Progress NoteEmergency Room RecordDischarge SummaryHistory & PhysicalConsultation(s)LabPathology ReportOperative Note(s)Imaging/X-RayEntire RecordOther (specify)
Health Information that may be used / disclosed is limited to the following periods of healthcare:
From: Date To: Date Account Number: Type a label
From: Date To: Date Account Number: Type a label
Health information to be released to the above named agency / individual is to be used / disclosed for the following purpose(s):

Treatment ConsultationAt Request of PatientResearchMarketingBilling or Claims PaymentAt Request of EmployerOther
"Health Information" identifies you (the patient) by name, and includes other demographic information about you. "Health Information" may include, but is not limited to: medical records, X-Ray films, slides, tracings, strips, etc.

I hereby discharge the releasing facility, its agents and employees from any and all liabilities, responsibilities, damages, and claims which might arise from the release of information authorized herein, to include alcohol, drug abuse, communicable disease including HIV status, and/or psychiatric diagnoses compiled during my visit, encounter or hospitalization, or make copies thereof in accordance with the policies of this facility.
YesNo
If applicable, I agree to the release of my medical or billing records containing the sensitive information listed above.
Protected Health Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and is no longer protected by this privacy rule. If research-related Health Information is used or disclosed for continued research purposes, an expiration date or event does not apply.

This authorization will automatically expire 60 days after the date of signature below (except as indicated below), unless an earlier is specified, or at the conclusion of a specified event. I understand that I have a right to revoke this authorization at any time, in writing, as stated in the Notice of Privacy Practices, except where the facility has already made disclosures in reliance upon my prior authorization.

Treatment, payment, enrollment or eligibility for benefits may not be conditioned on obtaining an authorization if the HIPAA prohibits such conditioning. If conditioning is permitted, refusal to sign the authorization may result in denial of care or coverage.

NOTICE TO RECEIVING AGENCY OR INDIVIDUAL: This information is to be treated in accordance with (HIPAA) privacy regulations.
Patient's Signature or Legal Representative
Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Relationship to Patient
Interpreter, if Utilized
Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Witness Signature
Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Expiration Date or Event

MonthDayYear
Date
*Signature validated against driver's license or signature in Medical Record. There may be a charge for copying Medical Records.Electronic copy requested.
Should be Empty: