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AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
TO REQUEST RELEASE OF MEDICAL INFORMATION PLEASE COMPLETE AND SIGN BELOW.
record.
, hereby voluntarily authorize the disclosure of information from my health
Patient Name
Record Number
Patient's Date of Birth

MonthDayYear
Date
Patient's SSN
Information Requested
Purpose of Release
The Information is to be provided to:

Name of Person/Organization/Facility Address:
Address
Phone Number
1.I understand that this authorization will expire on (insert date) 2.I understand that I may revoke this authorization (except to the extent that action was already taken in reliance on this signed authorization) at any time by notifying (insert name of practice) in writing.
(insert date)

MonthDayYear
Date
3. I understand that I can refuse to sign this authorization and that my refusal will not affect my ability to obtain treatment, payment or my eligibility for benefits (if applicable

4.I may inspect or copy any information used or disclosed under this agreement. 5.I understand that if the person or organization that receives the information is not a health care provider or plan covered by federal privacy regulations, the information described above may be redisclosed and would no longer be protected by these regulations.
Patient's Signature or Patient's Representative

Clear
Printed Name of Patient's Representative
Date

MonthDayYear
Date
Relationship to Patient
YOU HAVE THE RIGHT TO RECEIVE A COPY OF THIS FORM

Under HIPAA with patients' written request, records must be provided within 30 days of a request. Under House Bill 300 Texas Law with patients written request,records must beprovided within 15 days of a request.
HIPAA Authorization for Release of Information
This form does not constitute legal advice and covers only federal, not state, laws.
Should be Empty:

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AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS