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.
Patient Information

Choose one



This authorization is for the release of records pertaining to (check all that apply):


to




Reason for Releasing Records (check all that apply):





I would like my records to be (choose one):


This authorization shall be in effect until the information has been forwarded as requested or until the course of treatment is complete.
Patient Rights
  • 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.
Attach the appropriate files (if applicable)
 

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