HIPAA Authorization for Release of Medical Records

Patient Information

Name Date of Birth Address Phone Number

Recipient Information

Name/Facility Address Phone Number Fax Number

Information to be Released

Description of Records Date(s) of Service Purpose of Disclosure

Authorization

I authorize the release of my medical records as described above. I understand that this authorization is voluntary. I understand that I may revoke this authorization at any time by notifying the healthcare provider in writing, except to the extent action has already been taken in reliance on this authorization.
Expiration Date/Event

Signature of Patient or Authorized Representative Date If not patient, relationship to patient