Fillable Authorization To Release Medical Information (Page 3 of 3) in pdf

Advice for using the form:

In addition, in order for you to make the best use of this form, you should:

• Make a written request for copies of records, if possible.

• Specify the exact records you are requesting in a cover letter. You may

want to have a client check items to release that you do not need at the time. For

example, you may have the client check an item such as ‘Medication administration

logs…’ which may or may not be relevant to an investigation. You could then request

those records at a later time if necessary.

• Specify the period of time for which you are requesting records.

• Clearly specify the location to which the records should be mailed or another

method of delivery.

• It may be helpful to call some medical providers in advance to obtain an estimate of the

cost involved and the provider’s procedure for billing.

Note on records authorized to be released

All types of notes that you may need to request at any time from a particular provider should be

checked. Otherwise, you may need to have another authorization signed before requesting

additional records. There may be additional issues with some particular types of records:

• Records related to HIV status may not be released unless the individual has signed a

separate release specific to HIV related information. 5 U.S.C. §19203-D.

• Psychotherapy notes may not be released unless the individual has signed a separate

release specifying that such notes may be released. 45 CFR §164.508(b)(3)(ii).

• You must specify on the authorization the extent or nature of records to be released for

drug or alcohol records. 42 U.S.C. 290dd-3; 42 U.S.C. 290ee-3; 42 C.F.R., Part 2. The

individual may also use this section to limit other records to be released.

• ‘Medication administration logs…’ relates to information that is not a part of an

individual’s medical record. Such information may be particularly useful in abuse/

neglect investigations but must be specifically requested and have other patients’

information redacted. This is time-consuming and costly, and such records should only

be requested if necessary to investigate the specific allegations or a serious incident.

Note on statement of purpose

The statement of purpose should reflect the reason for the request. The client may elect to

check the last statement ‘other activities at the request of the individual’ if desired.

Note on patient representatives

If a patient’s representative is signing the authorization, you must specify the relationship of the

representative to the patient. Common relationships include:

• Parent or Guardian

• Conservator (a copy of the order appointing the conservator should also be provided)

• Attorney-in-fact (a copy of the notarized Power of Attorney should also be provided)

• Administrator of an Estate (a copy of the letters of administration from the court should

also be provided)

Authorization To Release Medical Information Page 3