• Authorization for Release, Use, and Disclosure of Health Information

  •  - -
  • Format: (000) 000-0000.

  • I authorize the use or disclosure of the above-named individual's health information as described below, by:

  • Format: (000) 000-0000.

  • I understand that the information in my health record may include information relating to sexuallytransmitted disease, acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus(HIV). It may also include information about behavioral or mental health services and treatment foralcohol and drug abuse.

    I authorize that this information may be disclosed to and used by the following individual ororganization:

  • I understand that I have a right to 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 the health information management department 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 on the following date event or condition    If I fail to specify an expiration date event or condition this authorization will expire in 365 days.

    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 to receive continued treatment. I understand that I may inspect or copy 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 an unauthorized redisclosure and the information may not be protected by federal confidentiality rules.

  • Clear
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  • Clear
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  • If signed by someone other than patient, please complete:

  • Clear
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  • Should be Empty: