Medical Authorization Template printable pdf download

This authorization allows the healthcare provider(s) named below to release confidential medical information and

records. Note: Information and records regarding treatment of minors, HIV, psychiatric/mental health conditions,

or alcohol/substance abuse have special rules that require specific authorization.

AUTHORIZATION

I hereby authorize:

Physician/Healthcare Facility

To release information regarding my medical history, illness or injury, consultation, prescriptions, treatment,

diagnosis or prognosis, including x-rays, correspondence and/or medical records by means of mail, fax or other

electronic methods.

To:

_______________________________________________________________

Name

_______________________________________________________________

Address

________________________________________

_______

_________

City

State

Zip Code

The medical information/records will be used for the following purpose: __________________________

This authorization is:

[ ] Unlimited (all records, excluding Substance Abuse, Mental Health, HIV Diagnosis/Treatment)

[ ] Limited to the following medical information: ____________________________________________

I also consent to the specific release of the following records:

Drug/Alcohol/Substance Abuse

_______ (initial)

Tests for Antibodies to HIV

_______ (initial)

Psychiatric/Mental Health

_______ (initial)

HIV Diagnosis/Treatment

_______ (initial)

DURATION This authorization shall be effective immediately and remain in effect until _____________

Date

RESTRICTIONS

Permissions for further use or disclosure of this medical information is not granted unless another authorization is

obtained from me or unless such disclosure is specifically required or permitted by law.

A photocopy of facsimile of this authorization shall be considered as effective and valid as the original.

I have been advised of my right to receive a copy of this authorization.

________________________________________

Signature of Patient

Relationship if other then patient

________________________________________

Patient’s Name (PRINT)

Date

________________________________________

Patient’s Social Security Number

Patient’s Date of Birth

________________________________________

Witness Name

Witness Signature

Medical Authorization Template

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