Medical Records Release Authorization

Medical Records Release Authorization
Patient Name:*
Date of Birth:*

MonthDayYear
Date
Phone Number:*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
1. I authorize the use or disclosure of the above named individual’s health information as described below.

2. The following individual or organization is authorized to make the disclosure:
Name of Clinic you would like to release your medical records: (If we are releasing records for you, please put New Path Medical Center here)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
3. The type and amount of information to be used or disclosed is as follows: (include dates where appropriate
Please choose which type of records you would like to be released:

Complete health recordsPhysical ExamImmunization RecordLab results / X-ray reportsConsultation ReportsOther
4. I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse.

5. This information may be disclosed to and used by the following individual or organization.
Name of clinic/person you would like your medical records to be released to: (If we are releasing records to you, please put your name here)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
For the purpose of:
6. I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the health information management department. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event, or condition:
Date

MonthDayYear
Date
7. If I fail to specify an expiration date, event or condition, this authorization will expire in sixty days. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact: Privacy Officer for Health.SOLUTIONS, LLC.
Signature of patient or legal representative

Clear
Date:*

MonthDayYear
Date
PLEASE NOTE: This information has been disclosed to you from confidential records protected from disclosure by state and federal law. No further disclosure of this information should be done without specific, written and informed release of the individual to whom it pertains or as permitted by state law (ORC – 3701.243) and federal law 42 CFR, part II.
Should be Empty: