Patient Authorization For The Release Of Medical Information Form


The Brooklyn Hospital Center
Patient Name _________________________________________________________Med. Rec. No. _________________________
Street/Apt. ____________________________________________________________Date of Birth _________________________
City, State, Zip ____________________________________________________Telephone No. ________________________
I hereby authorize the use and disclosure of my individually identifiable health information as described below. I understand
that this authorization is voluntary. I also understand that if a person or organization authorized to receive my information
is not a health plan or health care provider, the released information may be subject to re-disclosure and may no longer be
protected by the federal privacy regulations.
SECTION A - I am requesting the following information:
Medical Information covering records from (Date)______________________ to (Date)____________________________
Medical Information confined to the following specific information_____________________________________________
Abstract of Date: ____________ to (Date) _____________________
Please release information to:
Name: __________________________________________________________________________________________________
Address: ________________________________________________________________________________________________
For the purpose of ________________________________________________________________________________________
I understand that I will be charged $.75 a page for copying/faxing and additional charges for mailing this information.
SECTION B: To be read and initialed by patient/patient representative. THIS SECTION MUST BE COMPLETED.
This authorization/consent will expire when acted upon or 90 days from this date whichever occurs first.
1. I understand that I will get a copy of this form after I sign it.
Initial: _______
2. I understand that I may revoke this authorization at any time by
Initial: _______
notifying the Hospital in writing, but if I do, the revocation will
not have any effect on actions the Hospital has already taken in
reliance on this authorization.
3. I understand that this information may include:
 Behavioral Health/Psychiatry Care
Initial: _______
 Substance Abuse Care
Initial: _______
 HIV/AIDS related information
Initial: _______
Signature of Patient or Patient’s Representative
Printed Name of Patient or Patient’s Representative
Pick up
Relationship if signed by person other than patient
FAX# ___________
This form MUST be completed before signing


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Parent category: Legal