AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION
Date of Birth mm/dd/yyyy
Your First and Last Name
Your Doctor's name and Phone/Fax Number
Dates of Service- Request one year's worth of records. Ex: "04/01/20-Present"
Most patients send over their entire medical record to be safe.
History and Physical
Entire Medical Record:
To be disclosed for the following purpose(s): Write "Consult, not transferring"
Select Options if you want them removed from your records-most patient skip this.
Drug and/or alcohol abuse diagnosis and/or treatment
Sexually Transmitted Disease(s)
Expiration Date- Expires one year from Signature if left blank
Redisclosure of Information: I understand that once information is disclosed pursuant to this authorization that the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. Parts 160 and 164, protecting health information may not apply to the recipient of the information and, therefore, may not prohibit the recipient from re-disclosing it. Other laws, however, may prohibit redisclosure. Refusal to sign/right to revoke: I understand that I may refuse to sign or may revoke (at any time) this Authorization for any reason and that such refusal or revocation will not affect the commencement, continuation or quality of my treatment by my health care provider. Revocation: I understand that this Authorization will remain in effect until the term of this Authorization expires or I provide a written notice of revocation to my health care provider's Privacy Office at the address listed below. The revocation will be effective immediately upon my health care provider's receipt of my written notice, except that the revocation will not have any effect on any action taken by my health care provider in reliance on this Authorization before it received my written notice of revocation.
Signature of Parent, Guardian or Legal Rep. (if needed)
Should be Empty: