Authorization For Release Of Information

Patient Name:

Date of Birth:

Address:

City/State/Zip:

Telephone:

I authorize the release of medical information as indicated below:

FROM:

Practice Name:

Address:

TO:

Name:

Address:

I would like to pick up my records

Please call me at:

I would like to records mailed

Address

What to Release: Please choose the records you would like released:

Outpatient notes

X-Ray report(s)

Pathology Report(s)

Laboratory Reports

X-Ray Film(s)

Immunization record

All Medical records

Billing records

Other

Note: The records listed below have special protection by laws. I authorize the release of information pertaining to:

The diagnosis or treatment of AIDS, including results of HIV tests

Yes No/NA

The diagnosis or treatment of drug and/or alcohol abuse

Yes No/NA

The treatment and/or consultation for mental health or psychiatric disorders

Yes No/NA

Psychotherapy notes

Yes No/NA

Purpose of the release: Please indicate the reason for this release

For another doctor

Use in a lawsuit

Follow-up related to an injury

Personal use

To obtain disability

Worker’s care

Armed forces requirement

Other

if other, please specify

Format of the release:

Hardcopy format

Portable media device

Add Email

I understand that electronic media, and delivery methods such as unencrypted email, pose certain risks to the privacy and security of my Protected Health Information that may be beyond the control of

I agree to assume such risks personally, and to hold

harmless in the event my Protected Health Information is breached or compromised as a result of my directing and authorizing

to transmit or deliver such information electronically.

Expiration date: This authorization will expire in sixty days unless otherwise indicated below:

Please change the expiration date to

I understand this Authorization can be revoked at any time according the privacy practices of:

This request must be made in writing and sent to the same place as the original request.
Attach a copy of this release if possible. Treatment, payment, enrollment in any health plan is not conditioned on signing this authorization.

Once these records are released, the information is not protected by

and may potentially be re-disclosed by the party who received these records. its employees and officers, and attending physicians are released for legal responsibility or liability for release of the above information to the extent indicated and authorized.

I understand that I have the right to:

Inspect or copy the Protected Health Information to be used or disclosed as permitted under federal law (or state law to the extent the state law provides greater access rights.)
Have an electronic copy of my medical records, or a portion thereof, transmitted to any third party or person I designate.
Refuse to sign this Authorization.

I have read and understand this information. I have received a copy of this form and I am the patient or am authorized to act on behalf of the patient to sign this document verifying authorization for the use or disclosure of the protected health information under the above stated terms.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient

Date

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Legal Representative

Date

Your information will be encrypted.