Medical Records Release Form

Medical Records Release Form
Health Empowerment Network of Maryland, Inc. Authorization for the Release of Medical Information

This form authorizes Health Empowerment Network of Maryland, Inc. to release your personal health information as described below. Please read the instructions carefully and complete all required sections.
Patient Name
Date of Birth

MonthDayYear
Date
Address
Phone Number
Email Address
example@example.com
Please indicate the person(s) or organization(s) to whom you authorize the release of your medical records:
Name of Authorized Recipient eg doctor hospital organization
Phone Number
Fax NumberEmail if applicable
example@example.com
Please specify the purpose of this release of information. This can include but is not limited to: Continuity of Care Consultation with other healthcare providers Legal or insurance purposes Other (please specify):
Other please specify
Specific medical records Please specify
Diagnostic Test Results (e.g., lab results, imaging reports) Medication Records

Treatment and Medical History Other (please specify):
Other please specify
This authorization is valid for [Insert Time Period, e.g., 1 year] from the date it is signed or until the following event (if applicable):

This authorization will expire on: Other:
This authorization will expire on
Other
Right to Revoke Authorization:

You have the right to revoke this authorization at any time by submitting a written request to Health Empowerment Network of Maryland, Inc. The revocation will take effect when received, but it will not affect actions already taken based on this authorization.
This authorization is voluntary. Your treatment, payment, or benefits are not conditioned upon signing this authorization. Information disclosed under this authorization may be subject to re-disclosure by the recipient and may no longer be protected by privacy laws. Health Empowerment Network of Maryland, Inc. is not responsible for any further use of your medical information once it has been disclosed.

By signing below, I acknowledge and consent to the release of my medical information as described above. I understand that I may request a copy of this form for my records. Signature of Patient (or Guardian/Caregiver):

(If the patient is a minor or unable to sign, a legal guardian/caregiver must sign
Date

MonthDayYear
Date
Signature of Legal Guardian or Caregiver if applicable

Clear
Relationship to Patient
Date

MonthDayYear
Date
Name of Witness
Signature of Witness

Clear
Date

MonthDayYear
Date
Date Request Received: Processed by: Date Information Sent:
Date Request Received

MonthDayYear
Date
Processed by
Date Information Sent

MonthDayYear
Date
Please return this completed form to Health Empowerment Network of Maryland, Inc. via fax ator email at .

If you have questions about completing this form or need assistance, please contact us at

This Medical Records Release Form ensures that the release of medical information is clear, specific, and aligned with both the patient's preferences and legal requirements. It provides transparency, outlines the patient's rights, and follows best practices for maintaining confidentiality and compliance with privacy laws like HIPAA.
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