Authorization for Release of Information

Authorization for Release of Information
Name of Patient

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I, the above-named Releasor, hereby authorize:
Name of Releasee / Personal Information Controller
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
To release my medical records to
Recipient Organization
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Information to be Released (Check all that apply)

Complete Medical RecordsProgress NotesLab ReportsImaging/Radiology ReportsImmunization RecordsMental Health RecordsSubstance AbuseTreatment RecordsHIV/AIDS-Related InformationOther
Purpose of Disclosure

Continuation of CareInsurance PurposesLegal PurposesPersonal UseOther
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
Signature

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Date Signed

MonthDayYear
Date
Should be Empty: