Medical Record Release Form

Please correct the errors described below.

Patient Name

Date of Birth

SSN

My Authorization

I authorize

to use or disclose the following health information:

All of my health information

My health information relating to the following treatment or condition:

My health information covering the period

From

Other

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

Name or Organization

Address

City

State

Zip Code

Phone

Fax

Email address

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

At my request

Other

This authorization ends:

When the following event occurs

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

Signature of Patient

Date

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

Patient is a Minor

Years of age?

Patient is unable to sign because

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I request that my signature be represented by the above electronic signature and consent to recipients of electronic documents that I sign receiving personal information about me, including my email and IP addresses.

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