AUTHORIZATION TO RECEIVE MEDICAL RECORDS/INFORMATION

AUTHORIZATION TO RECEIVE MEDICAL RECORDS/INFORMATION

Complete this HIPAA-friendly authorization to confirm your authorization for the release of your medical records by the organization or physician listed below. Please provide only the information requested and use the signature section to authorize disclosure.
I authorize the release of my medical records by the organization or physician listed below:
Facility/Clinic Name
Provider's Name
Provider/Facility Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Provider/Facility Phone
Please enter a valid phone number.Format: (000) 000-0000.
Provider/Facility Fax
Provider/Facility Email
example@example.com
Reason for Disclosure of Records:
Patient Information
Patient's Full Name

First NameMiddle NameLast NameSuffix
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Last 4 digits of SSN
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Information to Release

The type and amount of information to be disclosed:
Choose the option below if you wish to release the entire record (required for new patients). Otherwise, skip to the next section to choose specific records.
Type of Information to Release
Imaging/X-Ray films Type and dates
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship to Patient
Patient Representative's Name (Only if filling on behalf of patient)

First NameLast Name
Patient or Patient Representative's Signature
Acknowledgments
I understand this authorization will expire, without my revocation, one year from the date of signing, or if I am a minor, on the date I become an adult according to the state law. I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken based on it. I understand that revocation will not apply to information that has already been released as specified by this authorization or to my insurance company. I understand that treatment, payment, enrollment, or eligibility of benefits will not be conditioned in obtaining your authorization for release of records. I understand that any disclosure of information carries with the potential for an unauthorized re-disclosure by the recipient and the information may not be protected by federal confidentiality rules.
I understand and acknowledge the terms of this release
Should be Empty:

AUTHORIZATION TO RECEIVE MEDICAL RECORDS/INFORMATION

I authorize the release of my medical records by the organization or physician listed below:

Patient Information

Information to Release

Signature

Acknowledgments