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
Date(s) Of Service: ________________________________________________
Diagnostic Studies: ______________
From: Name of Facility or Person: __________________________ Phone/Fax #:_________________________
Entity or Person who will receive the information
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
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.


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Parent category: Business