Authorization for Release of Patient-Identifiable Health Information
Authorization to Disclose Health Information
Patient Name:________________________________________ Health Record Number:________________________
Date of Birth:___________________________
1.
I authorize the use or disclosure of the above named individual's health information as described below.
2.
The following individual or organization is authorized to make the disclosure:
_____________________________________________________________________________________________
Address:_____________________________________________________________________________________
3.
The type and amount of information to be used or disclosed is as follows: (include dates where appropriate)
Medication List Immunization Record
History and Physical Discharge Information
Clinic Visit Note
Laboratory Results from (date) ____________________ to (date)_____________________
X-Ray Reports from (date) ____________________ to (date)_______________________
Consultation Reports from (doctor’s name(s)) _________________________________________________
Other _________________________________________________________________________________
_________________________________________________________________________________
4.
I understand that 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.
5.
This information may be disclosed to and used by the following individual or organization:
_____________________________________________________________________________________________
Address:______________________________________________________________________________________
For the purpose of:______________________________________________________________________________
6.
I understand that I have a right to 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 in one year.
7.
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 receive treatment. I understand that I may inspect or copy 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 re-disclosure and the information may not be protected by federal
privacy rules.
______________________________________________ _____________________________
Signature of Patient or Legal Representative Date
______________________________________________ _____________________________________
If signed by Legal Representative, Relationship to Patient Signature of Witness
