AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION

AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION
Patient Information:
Patient's Name:
Last, First Middle
Patient's DOB: *

Month Day Year
Date
Patient's Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Requesting records from:
Facility Name: *
Facility Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Fax Number: *
Please enter a valid phone number.
Phone Number:
Please enter a valid phone number.
Information to be released: *

Medical History, Exams, Reports Laboratory Reports Hospital Records & Reports Diagnostic Test Reports Surgical Reports/Operative Notes Consultations Reports Other
Purpose for Need of Disclosure *

At the request of the individual Other
I understand that the health information disclosed as a result of this authorization may no longer be protected by the federal privacy standards and my health information might be re-disclosed without obtaining my authorization.

I understand I have the right to:
- Receive a copy of this authorization
- Refuse to sign this authorization and that treatment, payment, enrollment in a health plan or eligibility for health care benefits may not be contingent on my signing this authorization
- Revoke this authorization, except to the extent that the person(s) and/or organization(s) listed above have already made in reference to this authorization
This authorization will remain in effect for 12 months from the date signed below.
Signature of Patient or Legal Representative: *

Clear
If signed by a Legal Representative (authority to act on patient's behalf): Relationship to Patient: Relationship
Should be Empty:

AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION

Patient Information:

Requesting records from: