Medical Release Form
Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance
Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)
I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form. In accordance with the Health Insurance Portability and Accountability Act of 1996, as codified at 42 U.S.C. §1320d et seq. (“HIPAA”) and the Health Insurance Technology for Economic and Clinical Health Act of 2009 (“HITECH”), I hereby authorize the providers listed below:
to RELEASE and DISCLOSE my entire medical record, including but not limited to patient histories, office notes, test results, radiology studies, pathology slides, films, referrals, consults, billing records, insurance records, records sent to you by other healthcare providers, and any other protected health information to These records are required to continue my care and provide me with treatment, review, or consultation.
I authorize the release of my complete health record with the exception of the following information:
Mental health records informationHIV and AIDS InformationAlcohol/drug abuse treatmentGenetic information
This authorization is fully understood and is made voluntarily on my part. I understand that my healthcare provider may not condition treatment or payment upon execution of this authorization. However, if I refuse to sign this authorization, then my healthcare provider may not be able to obtain my medical information. I understand that the information may be re-disclosed by the recipient and may no longer be protected by law. I hereby release my above listed healthcare provider and any of their HIPAA Business Associates involved in collecting my records from any legal liability that may arise out of the collection, gathering, scanning, digitizing, and release of the information requested. By signing below, I express my intent to be bound by this authorization. I understand that I may revoke this authorization at any time except to the extent that action based on this authorization has been taken. Cancellation of this authorization must be made in writing and faxed to 800-238-1195. This authorization expires one (1) year from the date it has been signed.
Printed name of patient or legal guardian (required)
Relationship to patient (required)
To use the signature field please draw your signature with your mouse, or on a touch-screen enabled device you can sign with your finger or pointing device.
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