Medical Record Release Form

Please correct the errors described below.

My Authorization

to use or disclose the following health information:

The above party may disclose this health information to the following recipient:

The purpose of this authorization is (check all that apply):

This authorization ends:

My Rights

I understand that I have the right to revoke this authorization, in writing, at any time, except where uses or disclosures have already been made based upon my original permission. I may not be able to revoke this authorization if its purpose was to obtain insurance. In order to revoke this authorization, I must do so in writing and send it to the appropriate disclosing party

I understand that uses and disclosures already made based upon my original permission cannot be taken back.

I understand that it is possible that information used or disclosed with my permission may be re-disclosed by the recipient and is no longer protected by the HIPAA Privacy Standards.

A copy of this authorization is as valid as the original and available upon request

If the patient is a minor or unable to sign, please complete the following:

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