Authorization To Release Medical Information
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3AUTHORIZATION TO RELEASE MEDICAL INFORMATION
I authorize the named health care provider to release the information or records specified to
upon request in person or by mail to the address specified at the time of the request.
Provider:
Patient:
(name and address)
SS#:
DOB:
RECORDS AUTHORIZED TO BE RELEASED:
Admission history and physical
Lab reports
Discharge summary
Radiological images
Complete hospital chart
Consultation notes or reports
Office notes
Complaints or grievances filed, with responses or
Outpatient records
dispositions
Psychiatric and other mental health records
Records relating to drug or alcohol abuse (must specify the extent or nature of the records to be released)
Medication administration logs, dietary logs, staff contact or service logs, and other records that may not be
part of my individual medical record, but which contain information relating to me
(These records should be redacted to protect information pertaining to other patients.)
Other (specify):
Extent or nature of records to be released:
(example, specific hospitalization or visit)
This information will be used for the purpose of :
Investigating an allegation of abuse
Verifying my eligibility for services offered by the
Providing advocacy services
Other activities at the request of the individual
Legal representation
This authorization will expire one year from the date of the signature below. I understand that I can
revoke this authorization at any time by writing to the health care provider or to the
, but that revoking this
authorization will not affect disclosures made or actions taken before the revocation is received.
I also understand that:
• I am not required to sign this authorization and
Patient or Representative
Date
that my health care or payment for care will
not be affected by my refusal.
• Federal privacy regulations will no longer
apply to the information disclosed, and that
may redisclose the information.
Name of Representative
(print)
• I am entitled to receive a copy of this
authorization.
• A copy of this authorization may be utilized
with the same effectiveness as an original.
Relationship to Patient
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Parent category: Legal