Health Information Release Template

AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION (HIPAA)

Date: Date

PATIENT INFORMATION

Patient Name: Full Legal Name

Date of Birth: DOB

Social Security Number (optional): XXX-XX-XXXX

Address: Patient Address

Phone: Phone Number

1. AUTHORIZATION TO RELEASE INFORMATION FROM:

Healthcare Provider/Organization: Name of Provider/Facility Releasing Information

Address: Address Phone: Phone Fax: Fax

2. AUTHORIZATION TO RELEASE INFORMATION TO:

Recipient Name: Name of Person/Organization Receiving Information

Recipient Type:

• Healthcare provider
• Insurance company
• Attorney
• Family member
• Other: Specify

Address: Address Phone: Phone Fax: Fax Email: Email

3. INFORMATION TO BE RELEASED

Select all that apply:

General Medical Information:

• Complete medical record
• Medical history and physical examination
• Progress notes
• Consultation reports
• Laboratory results
• Radiology/imaging reports and films
• Pathology reports
• Discharge summary
• Immunization records
• Billing and insurance records
• Dates of service

Specific Information:

• Records from specific date range: From Date to To Date
• Records related to: Specific condition/treatment
• Only the following: Specify

Sensitive Information (Requires Specific Authorization):

I specifically authorize release of the following (check to authorize):

• HIV/AIDS testing and treatment information
• Mental health records (psychotherapy notes)
• Substance abuse/drug and alcohol treatment records
• Genetic testing information
• Sexually transmitted disease information
• Reproductive health information
• Domestic violence information

Exclusions:

Do NOT release the following: Specify any exclusions

4. PURPOSE OF DISCLOSURE

Reason for Releasing Information:

• Continuing medical care
• Insurance/billing purposes
• Legal purposes
• Personal use
• Disability claim
• Workers' compensation
• School/employment requirement
• Other: Specify purpose

5. METHOD OF DELIVERY

Information May Be Released Via:

• Mail
• Fax
• Email (I understand email may not be secure)
• Electronic health record/portal
• Pick up in person
• Delivery to recipient
• Other: Specify

If Electronic Delivery:

I understand that electronic transmission carries some privacy risks and I accept these risks.

6. EXPIRATION

This Authorization Expires:

• On Specific Date
• One year from date of signature
• Upon completion of purpose: Describe event
• Does not expire (ongoing authorization)

Note: You may revoke this authorization at any time by notifying the provider in writing, except to the extent action has already been taken based on this authorization.

7. PATIENT RIGHTS AND IMPORTANT INFORMATION

I Understand That:

Right to Refuse:

• I do not have to sign this authorization
• My treatment, payment, enrollment, or eligibility for benefits cannot be conditioned on signing this authorization (with few exceptions)
• I may refuse to sign

Right to Revoke:

• I may revoke this authorization at any time by submitting written notice to: Provider Name and Address
• Revocation is not effective for actions already taken based on this authorization
• Revocation is not effective if authorization was obtained as a condition of obtaining insurance

Re-disclosure:

• Information disclosed pursuant to this authorization may be re-disclosed by the recipient and may no longer be protected by federal privacy regulations
• I understand information released may be subject to further disclosure by recipient

Copy of Authorization:

• I have the right to receive a copy of this signed authorization

Inspection:

• I have the right to inspect or copy the information to be disclosed (with some exceptions)

Fees:

• There may be a fee for copying records: Fee amount or "Contact provider"
• Payment due before release: Yes/No

Validity:

• This authorization is valid only if signed by patient or patient's legal representative
• Covers only the time period specified
• Does not authorize future creation of records

8. LEGAL REPRESENTATIVE (If Applicable)

If Not Signed by Patient:

Representative Name: Name

Relationship to Patient:

• Parent (if patient is minor under age X)
• Legal guardian
• Healthcare power of attorney/Healthcare proxy
• Personal representative of deceased patient (executor/administrator)
• Other legal authority: Specify

Documentation of Authority:

• Attached: Court order, POA document, death certificate, etc.
• On file with provider

9. ADDITIONAL INFORMATION

Special Instructions:

Any additional instructions or limitations

Delivery Instructions:

Specific delivery requirements if any

10. REQUIRED STATEMENTS

For Mental Health, Substance Abuse, or HIV/AIDS Records:

If This Authorization is for Mental Health Records:

I understand that my mental health records are protected under State law and cannot be disclosed without my written consent except in specific circumstances defined by law.

If This Authorization is for Substance Abuse Treatment Records:

This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

If This Authorization is for HIV/AIDS Information:

This information may include records of HIV (Human Immunodeficiency Virus) or AIDS (Acquired Immune Deficiency Syndrome), which are protected by State law. Unlawful disclosure or re-disclosure may result in fines or imprisonment.

11. ACKNOWLEDGMENT

I Acknowledge:

• I have read this authorization (or it has been read to me)
• I understand the information that will be disclosed
• I understand who will receive the information
• I understand the purpose of the disclosure
• I understand my rights, including the right to revoke
• I understand information may be re-disclosed and no longer protected
• I am signing this authorization voluntarily
• I have received a copy of this signed authorization

SIGNATURES:

Patient Signature (or Legal Representative):

Signature: _______________________

Printed Name: Patient Name or Representative Name

Date: _______________________

If Signed by Legal Representative:

Relationship to Patient: Relationship Authority: Legal basis - POA, Guardian, Parent, etc.

Witness (If Required by State Law):

Signature: _______________________

Printed Name: Name

Date: _______________________

FOR PROVIDER USE ONLY:

Date Received: Date

Received By: Staff Name

Date Information Released: Date

Released By: Staff Name

Released To: Recipient

Method: Mail/Fax/Email/Other

Expiration Date: Date

Notes: Any relevant notes

REVOCATION OF AUTHORIZATION (Use This Section to Revoke)

I hereby revoke the authorization dated Date of Original Authorization for release of my health information.

Patient Signature: _______________________

Printed Name: Name

Date of Revocation: _______________________

Note to Provider: Upon receipt of revocation, discontinue release of information. Place this revocation in patient's record. If information has already been released, note that in record.