RELEASE INFORMATION FORM

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Patient Name

First

Middle

Last

Date of Birth

Requested From (Provider Name)

Provider Email

Provider Phone

Provider Fax

Address

City

State

Zip

Send Information To (Name of Recipient)

Recipient Email

Recipient Phone

Recipient Fax

Reciipient Address

City

State

Zip

I authorize the release of the following health information:

All of my health information that the provider has in his or her possession, including information relating to any medical history, mental or physical condition and any treatment received by me.
Only the certain records or types of health information

(Purpose) I authorize the release of my health information for the following specific purpose:

At the request of the patient
Other purpose

Other Purpose

(Term) I understand that this Authorization will remain in effect:

From the date of this authorization to a specific date
Until the Provider fulfills this request
Until a specific event occurs

Redisclosure

I understand that my health care provider cannot guarantee that the recipient will not redisclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state law governing the use and disclosure of my health information.

Refusal to sign/right to revoke

I understand that signing this form is voluntary and that if I don’t sign, it will not affect the commencement, continuation or quality of my treatment. If I change my mind, I understand that I can revoke this authorization by providing a written notice of revocation. 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.

Authorization

I, First Name Last Name, authorize Name of Provider to release confidential health information about me. You may release a copy of my medical records, or a summary or narrative of my protected health information to Name of Recipient..

Patient

First

Last

Signature

Clear Signature

If Individual is unable to sign this Authorization, please complete the information below:

City Birth (Name

Name of Guardian

First

Last

Legal Relationship

Date

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