Authorization for Release of Medical Record Information

Last Name

First Name

M.I.

Date of Birth

Phone (Home)

Phone (Work)

Address

City

State

Zip

Please Note: Copy Fee May Be Charged For Medical Records

Above listed patient authorizes the following healthcare facility to make record disclosure:

Facility Name

Facility Phone

Facility Address

Facility Fax

City

State

Zip

Dates and 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 Physician

Continuation of Care (e.g., VA Med Ctr)

Referral

Other

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 other dates are specified.

I understand the information in my health record may include information relating to sexually 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 or organization:

Release To

Address

City

Zip

Please mail records

Please fax records

Fax

Phone

I understand I may revoke 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 in response to this authorization. I understand that the revocation will not
apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.

Unless otherwise revoked, this authorization will expire on the following date, event, or condition:

If I fail to specify an expiration date, event, or condition, this authorization will expire 1 year from the date signed.

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 disclosure 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 questions about
disclosure of my health information, I can contact the authorized individual or organization making disclosure.

I have read the above foregoing Authorization for Release of Information and do hereby acknowledge that I am
familiar with and fully understand the terms and conditions of this authorization.

Signature of Patient / Parent / Guardian or Authorized Representative

(Guardian or Authorized Representative must attach documentation of such status.)

Date

Printed name of Authorized Representative

Relationship / Capacity to patient

Address and telephone number of authorized representative

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