Authorization To Release Health Care Information Template printable pdf download

Authorization to Release Health Care Information

Patient’s name: _____________________________________ Date of birth: _________

SSN: _______________________ Previous name: _____________________________

Doctor’s Name __________________________________________________________

Practice Name: __________________________________________________________

I request and authorize the above listed doctor and practice to release health care

information of the patient named above to:

Name: __________________________________________________________________

Address: ________________________________________________________________

City, State: ________________________________________ Zip code: ______________

This request and authorization applies to health care information relating to the following

treatment, condition, or dates of treatment:

______________________________________________________________________

Or ________

All health care information

Or ________

Other: ________________________________________________

______________________________________________________

THIS AUTHORIZATION EXPIRES ON

__ DAYS AFTER

THE DATE IT IS SIGNED; or WHEN THE FOLLOWING EVENT OCCURS _____________

_________________________________________________________________________

I may cancel this authorization to the extent allowed by law. If I do, I understand that the doctor

or practice may have already released information about me after I gave permission. I know that

canceling this authorization would not prohibit any release of information by the doctor or practice

in reliance on my original authorization.

There are two ways to cancel this agreement. I can:



Sign and date a form available from the doctor or practice called “Revocation of

Authorization for Use and Disclosure of Health Care Information” or



Write a letter to the doctor or practice. If I write a letter, it must say that I want to cancel

my authorization to disclose my health care information. My letter must include the name

or other specific identification of the person(s) that I no longer want to receive

information. I (or my authorized representative) must sign and date the letter.

Once my doctor gives out the information that I want released, I know that my doctor has no

control over the information.

The individual or organization that I authorized to receive the

information might re-disclose it.

Federal or state privacy laws may no longer protect the

information.

________________________________________________________________________

Signature of patient or patient’s authorized representative

Date signed

________________________________________________________________________

Relationship or status if signed by parent, legal guardian, personal representative, etc.

Authorization To Release Health Care Information Template

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