Authorization For Release Of Health Information
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1
2AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION
Patient Name
Date of Birth
The above named person must indicate when this authorization is to expire:
When information is received
In one year
In six months
In three years
On date
The person named above is or has been a patient of
Name of Person,
Provider, or Facility
Address
Phone
Fax
The person named above hereby authorizes
to
Name of Person, Provider, or Facility
Request health information from
Send health information to
Discuss health information with
Discuss health information with
The person named above authorizes information to be requested or released by
representatives of
Name Of Person,
Provider, Or Facility
Address
Phone
Fax
Scope
All information regarding assessment, diagnosis, and treatment of patient s condition, concern,
or disease (specify):
All information regarding care received
by patient between the dates of
and
Starting Date
Ending Date
Other information (specify):
Authorization
Printed name of Patient or Authorized Representative
Signature of Patient
Date
Signature of witness
Date
or Authorized Representative
If not signed by the patient, indicate relationship of authorizing person to patient:
Parent or guardian of minor child
Guardian or conservator of conserved patient
Beneficiary or personal Representative of a deceased individual
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Parent category: Medical