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MEDICAL RECORD RELEASE

Authorization To Disclose Health Information & Release Record

Regarding Patient:

,
Phone:
Email:
Birthdate:

Information Released From:

,
Phone:

Information Released To:

,
Phone:

This Information Shall include the Following:

Date(s) of service to release:

NOTICE:

This authorization is for FULL DISCLOSURE OF ALL RECORDS, including clinical findings, diagnosis, treatment, assessment, recommendations for further care, name of health care personnel, dates of hospitalizations and ambulatory visits, charges, and any information that may be related to drug, alcohol, psychiatric conditions, and/or sexually transmitted disease, including HIV/AIDS information. Such records will be disclosed unless specified information to exclude is listed below.
Exclusions:

Purpose for Disclosure:

Restrictions:

I understand that the recipient of this information may not use or disclose the medical information unless another authorization is obtained from me or unless such use or disclosure is specifically required or permitted by law.

Legal Authority:

Other than patient:
For:

Authorization:

I hereby authorize disclosure of the health information to the above named patient. This authorization is valid for 90 days from the date of signature. I understand that I may cancel this request with written notification, but that it will not have any effect on information released prior to notification of cancellation.

Leave this empty:

Your legal name

Timestamp

Audit

December 5, 2018 6:43 pm EDT

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