Authorization to Release Medical Information

Authorization to Release Medical Information
Please complete all sections of this form, which will allow us to request your medical records from other health care clinicians you designate. Your information is HIPAA protected by all of us, and we work together to ensure confidentiality and privacy. Please do not leave any sections of this form blank, as this may delay our opportunity to request your medical records before your visit with us. We look forward to serving you.
Section I
I, First Name* Last Name* give my permission for Name of Healthcare Organization* (insert name of organization that will provide medical records to be shared with My Heart Spark P.C.) to share the information listed in Section II of this document, with My Heart Spark P.C. as I have specified in Section IV of this document.
Section II - Health Information
Name*
Organization (Insert name of organization that will provide medical records to be shared with My Heart Spark P.C.)*
Address*
Fax*
Please enter a valid phone number.
Email*
example@example.com
I would like to give the above healthcare professional(s)/organization(s) permission to:*

Disclose my complete health record including, but not limited to, diagnoses, lab and imaging test results, treatment, and billing records for all conditions.Disclose my complete health record except for the following information:
Please indicate what should NOT be shared:

Mental health recordsCommunicable diseases including but not limited to, HIV and AIDSAlcohol/drug abuse treatment recordsGenetic InformationOther
Form of Disclosure:*

Electronic copy or access via a web-based portal
Section III - Reason for Disclosure
Please detail the reasons why information is being shared. If you are initiating the request for sharing information and do not wish to list the reasons for sharing, write "at my request".*
Section IV - Who Can Receive My Health Information
I give authorization for the health information detailed in Section II of this document to be shared with the following organization(s):
Organization*
Organization*

My Heart Spark P.C.
Address*
Fax*
Please enter a valid phone number.
Email*
example@example.com
Section V - Duration of Authorization
This authorization to share my health information is valid:*

Starting and ending on the two dates below (This means we will need you to complete a new form periodically);All past, present, and future periods (This means you should only need to complete this form for us once);The date of the signature in section VI until the following event (This means we will need you to complete a new form periodically).
This authorization is valid from:

MonthDayYear
Date
To:

MonthDayYear
Date
This authorization is valid until the following event:
I can revoke my permission for authorization to share my medical records at any time by sending a written letter to the following.

My Heart Spark P.C.

1200 Brickell Avenue, Suite 1950 #1005

Miami, FL 33131
I understand that:
- In the event that my information has already been shared by the time my authorization is revoked, it may be too late to cancel permission to share my health data.
- I understand that I do not need to give any further permission for the information detailed in Section II to be shared with the person(s) or organization(s) listed in Section IV.
- I understand that the failure to sign/submit this authorization or the cancellation of this authorization will not prevent me from receiving any treatment or benefits I am entitled to receive, provide this information is not required to determine if I am eligible to receive those treatments or benefits or to pay for the services I receive.
Section VI - Signature
I attest that my electronic signature on this form is to have the same legally binding effect as my traditional handwritten signature. I am 18 years of age or older, and I am authorized to sign this form on my own behalf.
Name of person completing this form*
Signature*

Clear
Date Signed*

MonthDayYear
Date
Describe below how this person has legal authority to sign this form (e.g., “Self”):
If you would like to receive a copy of your completed form, please provide your email address:
example@example.com
This form will now end after this next message; submit the form, then we will immediately take you to the list of crucial forms so you can see if you got them all! We can't wait to see you soon. :)
Should be Empty:

Authorization to Release Medical Information

Section I

Section II - Health Information

Section III - Reason for Disclosure

Section IV - Who Can Receive My Health Information

Section V - Duration of Authorization

Section VI - Signature