Release of Medical Information

Third Party Authorization to Release Medical Information
Patient Name:*
Date of Birth:*

MonthDayYear
Date
I request that my protected health information be disclosed from (Practice sending records):
Facility/Clinician/Person:*
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*
Format: (000) 000-0000.
I request that my protected health information be disclosed to (Practice acquiring or receiving records):
Facility/Clinician/Person:*
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*
Format: (000) 000-0000.
I authorize the following protected health information to be released from my medical record(s):
Release medical records from between these dates
Starting date of records to be released

MonthDayYear
Date
Last date of records to be released

MonthDayYear
Date
Include the following medical record types:

Office NotesTest Results (Lab, X-Ray, Pathology)Billing RecordsOther (immunization records, medications, and any other listed below)
Other medical record types to include in release
I understand that the information in my medical record may include information relating to sexually transmitted disease (STD), Acquired Immunodeficiency Syndrome (AIDS), or Human Immunodeficiency Virus (HIV). It may also include information about behavioral or mental health services, and alcohol or drug abuse. Federal law protects the following information. If this information applies to you, please indicate if you would like this information released/obtained (include dates where appropriate):
Alcohol, Drug or Substance Abuse Records

YesNo
Include alcohol, drug, or substance abuse records between the following dates:

From Date to Date
Type a question
HIV Testing and Results

YesNo
Include HIV testing and results between the following dates:

From Date to Date
Type a question
Mental Health

YesNo
Include mental health records from between the following dates:

From Date to Date
Type a question
Purpose for requesting information:

Personal UseContinued CareLegal PurposesInsurance PurposesOther
By signing this authorization form, I understand that:
1. I have a right to withdraw this authorization at any time. Request to withdraw must be made in writing and presented to Practice. I understand that stopping this release will not apply to information that has already been released.
2. This authorization will expire (insert date or event) . If I fail to specify an expiration date or event, this authorization will expire go days from the date it was signed.
3. Treatment, payment, enrollment, or eligibility for benefits may not be conditioned on whether I sign this authorization.
4. Once the above information is disclosed, it may be re-disclosed by the recipient and the information may not be protected by the federal privacy laws or regulations.
5. I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment or payment or my eligibility for benefits. I may inspect or obtain a copy of any information used or disclosed under this authorization.
6. Requests for copies of medical records are subject to reproduction fees in accordance with federal/state regulations.
ACKNOWLEDGEMENT
Patient OR parent, guardian, authorized representative signature X
Date*

MonthDayYear
Date
Should be Empty:

Third Party Authorization to Release Medical Information

I request that my protected health information be disclosed from (Practice sending records):

I request that my protected health information be disclosed to (Practice acquiring or receiving records):

ACKNOWLEDGEMENT