Authorization For Release Of Protected Health Information

Download a blank fillable Authorization For Release Of Protected Health Information in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Authorization For Release Of Protected Health Information with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.


Authorization for Release of Protected Health Information
Patient Identification
Printed Name: ___________________________________________ Date of Birth: _______________________
Information is to be released by:
Information is to be sent to:
(Physician or Facility)
(Individual/ Agency/ Facility)
(Street Address)
(Street Address)
(City, State and Zip Code)
(City, State and Zip Code)
(Telephone Number)
(Telephone Number)
Information To Be Released – Covering the Periods of Health Care
From (date) ___________________________________ to (date) ______________________________________
Please check type of information to be released:
Complete health record
Diagnosis & treatment codes
Discharge summary
Laboratory test results
Complete billing record
X-ray films / images
Other (specify)
Purpose of Request
Treatment or consultation
At the request of the patient
Billing or claims payment
Other (specify)
Drug and/or Alcohol Abuse, and/or Psychiatric, and/or HIV/AIDS Records Release
I understand if my medical or billing record contains information in reference to drug and/or alcohol abuse, psychiatric care, sexually
transmitted disease, Hepatitis B or C testing, and/or other sensitive information, I agree to its release. Check One:
I understand if my medical or billing record contains information in reference to HIV/AIDS (Human Immunodeficiency Virus/Acquired
Immunodeficiency Syndrome) testing and/or treatment I agree to its release. Check One:
Time Limit & Right to Revoke Authorization
Except to the extent that action has already been taken in reliance on this Authorization, you have the right to revoke this Authorization by
submitting a notice in writing to the Department of HIS or other Department to whom you are authorizing disclosure. Unless revoked, this
Authorization will expire on the following date or event _________________________________, or 90 days from date of signature, unless
otherwise specified.
I understand the information released pursuant to this Authorization may be subject to re-release by the recipient and no longer protected by
the Health Insurance Portability and Accountability Act of 1996. The facility, its employees, officers and physicians are hereby released from
any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.
Signature of Patient or Personal Representative Who May Request Disclosure
Your provider will not deny treatment if you do not sign this form. You may inspect or copy your protected health information. By signing
below, you authorize your provider, identified above, to release your protected health information specified above.
Signature: _____________________________________________________ Date: _____________________
Authority to Sign - if not patient: ___________________________________Witness:_________________________
Identity of Requestor Verified via:
Photo ID
Matching Signature
Other, specify _____________________________
ID Verified by: _________________________________________________________


00 votes

Related Articles

Related forms

Related Categories

Parent category: Business