Medical Records and Health Care Information Release

Authorization for Use/Disclosure of Protected Health Information

Please correct the errors described below.

to release, use or disclose Medical Records as described below:

This Authorization applies to the following date(s) of Service:

Add additional dates

State Requirements for Complete Medical Records

Search, Retrieval & Other Direct Administrative Costs

Up to: $25.88

Copying Costs for Records in Paper form

Per page for pages 1-20: $0.97,
Per page for pages 21-100: $0.83,
Per page for pages over 100: $0.66

Where would you like requested records sent?

I understand that the information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient of the information and may then no longer be protected by the federal privacy regulations. I understand that unless otherwise limited by state or federal regulations, I may revoke this Authorization at any time by presenting my revocation in writing except to the extent that the entity identified above has taken action in reliance on this Authorization. I further understand that this Authorization is specific to the information checked above, for the date(s) of service indicated, and for the purpose written above.

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

    Please upload a file

    Your information will be encrypted.