Authorization For Release Of Protected Health Information
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1AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION
Patient Name:
Date of Birth:
Address:
SS #::
Phone:
Date of Service:
I hereby authorize (Facility/Program)
to
Release my medical records to (complete name and address):
Please release the
Entire Medical Record OR the following information (Check all that apply):
History and Physical
Operative/Pathology Report
Method of Release
Consultation Report
Pathology Slides/Block
X-ray/Imaging Report(s)
Lab Report(s)
Paper
X-rays/Imaging Film
Emergency Room Record
CD/DVD
Mammography
Discharge Summary
Flash Drive Provided
(Original, not copy)*
Photo(s)
Abstract or Summary
Secure Website
Other
Please complete each of the following statements. If not complete, the information will not be released.
I
do
do not
want HIV/AIDS information released under this authorization.
I
do
do not
want mental health information released under this authorization.
I
do
do not
want drug/alcohol abuse treatment information released under this authorization.
I
do
do not
want developmental disability treatment information release under this authorization.
The purpose for release of the above information:
Continued Care
Insurance
Legal
At my request
Other:
(Patient only)
This authorization will expire within 1 year unless otherwise indicated. I understand that authorization is voluntary and
may be revoked at any time in writing except to the extent that action has already been taken in reliance to this
authorization. Subsequent re-disclosure or recopying of this information is not authorized without specific consent of the
patient or authorized representative as provided in the Annotated Code of the State of Maryland, Article 4-302 (d).
I understand that I do not have to sign this authorization to ensure that I receive medical care.
___________________________________________________
________________________________
Signature of Patient/Patient Representative
Date
___________________________________________________
Witness
If signed by other than patient, state relationship:
Parent
Guardian
Legal Representative
Other:
* Photo ID is required at the time of release.
Information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and will no longer
be protected by the Health Insurance Portability and Accountability Act.
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