Patient Authorization Form

Patient Authorization Form

AUTHORIZATION FOR RELEASE OF MEDICAL RECORD INFORMATION
Patient Name:

First NameLast Name
Date of Birth:

MonthDayYear
Date
Phone(H):
Please enter a valid phone number.
Phone(M):
Please enter a valid phone number.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Facility Name:

First NameLast Name
Facility Phone:
Please enter a valid phone number.
Facility Fax:
Please enter a valid phone number.
Facility Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dates & Type of Information to Disclose:

2 years prior from last date seen
Dates (other):
Specific Information Requested:
The Purpose of Disclosure is:

Change of Insurance or PhysicianContinuation of CareReferralOther:
RESTRICTIONS: Only medical records originated through this healthcare facility will be copied unless otherwise requested. This authorization is valid only for the release of medical information dated prior to and including the date on this authorization unless otherwise specified.
I understand that the information in my health record may include information relating to sexual 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.
This information may be disclosed and used by the following individual and organization:
Release to:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:
Please enter a valid phone number.
Fax:
Please enter a valid phone number.
Mail RecordsFax Records
I understand I may revove 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 information that has already been released I response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurance 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
If I fail to specify an expiration date, event, or condition, this authorization will expire 1 year from the signed date.
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 obtain a copy of the information to be used or disclosed as provided in CFR 164.524. I understand that any discloser 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 any questions about the disclosure of my health information, I can contact the authorized individual or organization making disclosure. I have read the above foregoing Authorization of Release of Information and hereby acknowledge that I am familiar with and fully understand the terms and conditions of this authorization.
Parent/ Guardian/ Authorized Representative Signature:

Clear
Printed Name of Authorized Representative:

First NameLast Name
Relationship:
Date:

MonthDayYear
Date
Should be Empty:

Patient Authorization Form

This information may be disclosed and used by the following individual and organization: