Authorization to Release Health Information
* = required fields
Please be aware that there is a charge per page of medical records given directly to the patient.
Please allow 5-10 days for records to be copied. Thank you.
Name of Patient
Date of Birth
Release and Send my Medical Records TO
– or –
Obtain my Medical Records FROM
This authorization is for the release of records pertaining to (check all that apply):
Office Visit Notes
Care and Treatment for dates from
On Site Record Review by Patient
Marketing (Financial compensation is received for this request.)
Psychotherapy Notes—if this box is checked, only psychotherapy notes may be released.
Other as Listed
Reason for Releasing Records (check all that apply):
Providing copy to Primary Care Physician
Dissatisfaction with Practice
I intend to transfer my care to another practice
I would like my records to be (choose one):
Faxed (limit 10 pages)
This authorization shall be in effect until the information has been forwarded as requested or until the course of treatment is complete.
I have the right to revoke this authorization at any time.
I may inspect or copy the protected health information to be disclosed as described in this document.
Revocation is not effective in cases where the information has already been disclosed but will be effective going forward.
Information used or disclosed as a result of this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law.
I may refuse to sign this authorization and that my treatment will not be conditioned on signing.
I understand released information may include a communicable disease diagnosis such as HIV as well as diagnosis of alcohol/drug abuse or mental health.
Patient or Personal Representative Signature
– Draw your signature below using a tablet, mouse or smartphone.
By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Description of Personal Representative’s Authority
Attach the appropriate files (if applicable)