This document serves as a formal authorization for the use and/or disclosure of confidential information, including protected health information (PHI), in compliance with applicable privacy laws and regulations.
Full Legal Name
Date of Birth
Street Address
Street Address Line 2
City
State/Province
Postal/Zip Code
Phone Number
Email Address
I hereby authorize the following individual(s), organization(s), or entity(ies) to release the information described below:
Name of Organization/Entity
Contact Person/Department
Street Address
Street Address Line 2
City
State/Province
Postal/Zip Code
Phone Number
Purpose of Disclosure
Please clearly tick ✅ specific information to be released. If All is selected, all information held by The Holder pertaining to the Individual will be released.
Type of Information | Select | Specify Date Range (If applicable) | ||
|---|---|---|---|---|
1 | All Medical Records | |||
2 | Specific Records Only (Please specify below) | |||
3 | Medical History and Physical Exam | |||
4 | Discharge Summaries | |||
5 | Progress Notes/Clinic Visits | |||
6 | Laboratory Reports | |||
7 | Radiology/Imaging Reports | |||
8 | Billing/Insurance Information | |||
9 | Mental Health Records (Specific Consent Required) | |||
10 | Substance Use Disorder Records (Specific Consent Required) |
Specific Records Details (If "Specific Records Only" is selected):
Right to Revoke: I understand that I may revoke this authorization at any time by notifying the party authorized to release the information (The Holder) in writing, except to the extent that action has already been taken in reliance on this authorization.
Re-disclosure: I understand that once the information is disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by the privacy rules.
Treatment Condition: I understand that the ability to obtain treatment, payment, enrollment in a health plan, or eligibility for benefits is not conditioned upon signing this authorization, unless the requested information is necessary to determine eligibility for benefits.
Copy: I have been provided with a copy of this completed authorization form.
Specify Date
Specify Event/Condition
If left blank, this authorization is valid for one year from the date of signature.
I certify that I am the individual whose information is to be released, or a legally authorized representative (e.g., Parent, Guardian, Executor).
Signature of Individual or Legal Representative
Relationship to Individual (if not the Individual)