Authorization for Release of Medical Records

Patient Information

• Full Name: _________________________ Date of Birth: //___
• Previous Name (if applicable): _________________________
• Phone: (__) - Email: _________________________
• Address: _______________________________________________

Release Information

Records Released From:

• Practice Name: _________________________________________
• Provider Name: ________________________________________
• Address: _____________________________________________
• Phone: () - Fax: () -

Records Released To:

• Practice/Entity Name: __________________________________
• Provider Name: ________________________________________
• Address: _____________________________________________
• Phone: () - Fax: () -

Information to be Released

• Complete Medical Record
• Lab Results
• Imaging Reports
• Immunization Records
• Medication List
• Progress Notes
• Other: ___________________________________________

Date Range: From //___ To //___

Sensitive Information Authorization

I specifically authorize the release of the following information (initial): ___ HIV/AIDS Testing & Results ___ Mental Health Records ___ Substance Use Treatment Records ___ Genetic Testing Information

Purpose of Release

• Continuing Medical Care
• Insurance
• Legal
• Personal Use
• Other: ___________________________________________

Authorization & Rights

I understand that:

1. This authorization expires one year from the date signed
2. I may revoke this authorization at any time in writing
3. Treatment is not conditional upon signing this authorization
4. Once information is released, it may be redisclosed and no longer protected

Signature: _________________________ Date: //___

Printed Name: _________________________

Relationship to Patient (if not self): _________________________