Authorization To Release Health Information Form printable pdf download

Authorization To Release Health Information Form

Authorization to Release Health Information

Patient Information

Name of Patient:________________________________ Date of Birth:__________________

Mailing Address: ______________________________________________________________

City, State, Zip: __________________________ Phone: ______________________________

At my request, I __________________________________________ , do hereby authorize the release of:

Patient Name or Legal Guardian

Op Report

Entire Record

Office Visit Note: ___________

Financial Records

On Site Review By Patient

Other:_____________________

Date(s) Of Service: ________________________________________________

Diagnostic Studies: ______________

From: Name of Facility or Person: __________________________ Phone/Fax #:_________________________

Entity or Person who will receive the information

Name:________________________________________________________________________

Mailing Address: _______________________________________________________________

City, State, Zip: ________________________________________________________________

Phone: ________________________________ Fax:__________________________________

Purpose of Disclosure: __________________________________________________________

I hereby authorize disclosure of the health information for the above named patient. This authorization is valid until revoked in writing

by the patient. I understand that I may cancel this request with written notification but that it will not affect any information release

prior to notification of cancellation. I understand that the information used or disclosed my be subject to re-disclosure by the person or

class of persons or facility receiving it, and would then no longer be protected by federal regulations. I understand that the medical

provider to whom this authorization is furnished may not condition its treatment of me on whether or not I sign the authorization.

_________________________________________________

____________________________

Signature of Patient or Guardian or Personal

Date

Representative of patient’s estate

NOTE: There will be a charge for a personal copy or the permanent transfer of your reports. Healthport has been contracted to provide this

service and will invoice you directly.

Authorization To Release Health Information Form