Authorization To Release Medical Information Page 2
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3Instructions for Authorization to Release Medical Information
Instructions
• You can fill this form in on the computer for printing.
• When filling in the form on the computer, you can move between fields by using the TAB
key, the ARROW KEYS, or the mouse. The SPACE BAR or a MOUSE CLICK will
check or uncheck boxes.
• If you fill in too much text in a blank, the text block may be extended and the signature
block may be forced onto a second page. This is okay, and this is also why the second
page of this document is blank.
• You can print the form for signing after filling in the blanks. You do not need to save a
copy to your computer.
• To simplify completing a copy of the form for many different providers, you may save a
partially completed copy of the form on you computer and change only the provider or
other information necessary for each additional copy before printing.
Explanation of HIPAA
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires an
Authorization to Release Medical Information in order for health care providers to release
medical information or records. New requirements for authorizations became effective April
16, 2003. This requirement also extends to organizations related to health care providers,
such as insurance companies and other organizations closely associated with health care
providers, and their contractors. It is necessary to use this form when requesting information
from health care providers because this law requires specific information to be provided on an
authorization. This form should not be used to request records not covered by HIPAA (records
obtained from a source other than a health care provider).
Medical providers are mandated to protect information and to require the use of forms that
comply with the law. This form complies with the requirements of HIPAA and should be
accepted by all medical providers. However, if a medical provider insists that the provider’s
form be used, you may want to use that form if it will expedite the process of obtaining records.
Please notify the AWPPW if this situation arises so that the problem can be resolved.
Requirements for using the form:
HIPAA also requires specific steps in obtaining and utilizing an authorization to release medical
information. Therefore, it will be necessary that you:
• Utilize one form for each medical provider from whom records are requested.
• Complete the forms in their entirety before asking a client to sign the form.
• Date the form at the time it is signed.
• Provide a copy of each completed form to the client.
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