Authorization for Release of Information

Patient Information

Information to be released from: Name of Organization or Provider

Information to be sent to:

Information to be released: (please check one)

Purpose for which information is being used: (please check one)

Patient Authorization:

I understand that my records may contain information regarding the diagnosis or treatment of HIV/AIDS, sexually transmitted diseases, drug and/or alcohol abuse, mental illness, or psychiatric treatment. I give my specific authorization for these records to be released.

Please initial the following to have the information excluded from the records:

My Rights:

I understand I do not have to sign this authorization in order to obtain health care benefits (treatment, payment, or enrollment). I may revoke this authorization in writing. To view the process for revoking this authorization, please read the Privacy Notice to patients at the facility where your information is being released. I understand that once the health information I have authorized to be disclosed reaches the recipient, that person or organization may re-disclose it, at which time it may no longer be protected under Privacy Laws. This authorization will EXPIRE 90 days from date signed.

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.

*There is a .50 per page charge to release records for personal use.*