Authorization To Release Medical Information Form

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Authorization to Release Medical Information
Patient Name: ________________________________
Date of Birth: __________________
Address:
________________________________
Phone:
___________________
City:
______________ State: ______
Zip: ______
I authorize the release of the following protected health information:
□ Office Notes /Name of Physician __________________________________________________
□ Pathology Reports
□ Radiology Reports
□ Laboratory Reports Date(s): ___________
□ Other:_________________ □ Paper Copy
□ Electronic Copy
The purpose for this request to release medical information is:
□ Medical Care / Treatment
□ Insurance
□ Other (specify)_________________
Send my medical information to: Name:
_________________________________________
Address:
_________________________________________
City, State, Zip: _________________________________________
I understand that:
By signing this form, I am authorizing the use or disclosure of protected health information as
indicated above.
I may refuse to sign this authorization, which will not affect my treatment or payment for health care.
I may revoke this authorization at any time before the information I have requested is released by providing
written notice of revocation as specified in the Notice of Privacy Practices.
If the receiving party is not subject to medical records privacy laws, the information may be re-
disclosed by the recipient and may no longer be protected by federal or state law. Columbia University
Medical Center shall not be held liable for any consequences resulting from re-disclosure
If the information to be released contains any information about HIV/AIDS an additional HIPAA
release of medical information for will be requested.
Alcohol or substance abuse, mental health or psychiatry notes may have additional compliance
requirements that must be met before the information can be released.
A copy of this signed form will be provided to me.
CUMC may charge an administrative fee to cover the cost of labor, copying, and postage. The
physician’s office will inform me of any charges and arrange for payment.
This Authorization expires on __ /
/ __
{if date not completed / one year after signed}
_______________________________________
__________________________
Patient / Representative Signature
Date
If the patient listed above is a minor or is unable to sign and you are a parent, legal guardian, or
personal representative signing on behalf of this patient, please sign above and complete the
following:
____________________________________
___________________________________
Print Name
Relationship to patient
Retain this form in the patient's medical record and provide a copy to the patient.
An additional authorization (NYS DOH-2557) is required for disclosures when your medical records contain information
relating to Acquired Immunodeficiency Syndrome (AIDS), or Human Immunodeficiency Virus (HIV) including but not limited
to test results and the fact that the test was taken.
Approved August 11, 2008

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