Authorization for Release of Medical Records

HIPAA-Compliant Authorization

1. Patient Information

Patient Name: patient_name

Date of Birth: _______________

Address: _______________

Phone: _______________

Email: _______________

2. Provider / Facility Releasing Records

Name: provider_name

Address: _______________

Phone: _______________

Fax: _______________

3. Recipient of Records

I authorize the release of my medical records to the following individual, organization, or entity:

Recipient Name: recipient_name

Address: _______________

Phone: _______________

Fax: _______________

Email: _______________

4. Specific Records Authorized for Release

4.1 Date Range

I authorize the release of medical records from the following date range: records_date_range.

4.2 Types of Records

I authorize the release of the following types of records (check all that apply):

[ ] Complete medical records for the specified date range

[ ] Office/clinic visit notes

[ ] Hospital records (admission, discharge summaries, operative reports)

[ ] Laboratory and pathology results

[ ] Radiology/imaging reports and images

[ ] Prescription and medication records

[ ] Immunization records

[ ] Mental health/behavioral health records

[ ] Substance abuse/chemical dependency treatment records

[ ] HIV/AIDS-related information

[ ] Genetic testing results

[ ] Billing and insurance records

[ ] Other (specify): _______________

4.3 Sensitive Information

I specifically authorize the release of the following sensitive information, if contained in my records (initial each category you wish to authorize):

_____ Mental health/psychiatric records

_____ Substance abuse treatment records (42 CFR Part 2)

_____ HIV/AIDS test results and treatment records

_____ Sexually transmitted disease records

_____ Genetic testing information

I understand that some categories of sensitive information are subject to additional legal protections and that my authorization must specifically cover each category for release to be permitted.

5. Purpose of Disclosure

The purpose of this disclosure is (check all that apply):

[ ] Continuity of care / transfer of care to a new provider

[ ] Consultation with a specialist

[ ] Insurance/billing purposes

[ ] Legal proceedings

[ ] Personal/patient request

[ ] Disability determination

[ ] Workers' compensation claim

[ ] Life insurance application

[ ] Research

[ ] Other (specify): _______________

6. Form and Method of Delivery

I request that my records be delivered in the following format:

[ ] Paper copies, mailed to the recipient's address

[ ] Electronic format, via secure email or encrypted portal

[ ] Fax, to the recipient's fax number

[ ] In person, to the patient or authorized representative

I understand that electronic transmission carries inherent risks and that the provider will use reasonable security measures to protect my information during transmission.

7. Expiration

7.1 Expiration Date

This authorization shall expire on the earlier of: (a) the date specified here: _______________; or (b) one hundred eighty (180) days from the date of signature, if no expiration date is specified; or (c) upon written revocation by the patient.

7.2 Event-Based Expiration

Alternatively, this authorization shall expire upon the occurrence of the following event: _______________ (e.g., completion of the legal proceeding, conclusion of the insurance claim, etc.).

8. Right to Revoke

I understand that I have the right to revoke this authorization at any time by providing a written request to provider_name. I understand that revocation will not affect any disclosures that have already been made in reliance on this authorization prior to the receipt of my written revocation.

To revoke this authorization, I must submit a written request to the provider's Privacy Officer or medical records department. Revocation shall be effective upon receipt of the written request.

9. Re-Disclosure Warning

I understand that once my health information has been disclosed to the recipient, it may no longer be protected by HIPAA and may be subject to re-disclosure by the recipient. The recipient may not be required to comply with HIPAA, depending on the recipient's status under the law.

However, certain categories of information (such as substance abuse treatment records protected under 42 CFR Part 2) carry additional restrictions on re-disclosure, and the recipient must comply with those restrictions.

10. HIPAA Rights

10.1 Right to a Copy

I have the right to receive a copy of this authorization after I sign it.

10.2 Conditioning of Treatment

I understand that provider_name may not condition my treatment, payment, enrollment in a health plan, or eligibility for benefits on whether I sign this authorization, except in limited circumstances permitted by law (such as research-related treatment or eligibility for coverage).

10.3 Right to Inspect Records

I understand that I have the right to inspect and obtain a copy of the health information that is the subject of this authorization, in accordance with HIPAA's right of access provisions.

10.4 Fees

I understand that the provider may charge a reasonable fee for copying and transmitting my records, in accordance with applicable state law. The provider shall inform me of any fees before processing this request.

11. Patient Acknowledgments

By signing below, I, patient_name, acknowledge and confirm that:

(a) I have read and understand this authorization;

(b) I have had the opportunity to ask questions about this authorization;

(c) I am signing this authorization voluntarily;

(d) I understand my right to revoke this authorization at any time;

(e) I understand the re-disclosure warning described above;

(f) I authorize the release of the specific records described above for the purpose stated;

(g) I have received or been offered a copy of this signed authorization.

12. If Signed by Authorized Representative

If this authorization is signed by someone other than the patient, the following information is required:

Representative Name: _______________

Relationship to Patient: _______________

Legal Authority (e.g., power of attorney, legal guardian, executor): _______________

The representative certifies that they have the legal authority to sign this authorization on behalf of the patient.

IN WITNESS WHEREOF, the undersigned has executed this Authorization for Release of Medical Records.

Patient

patient_name

[Electronic signature will be collected via zsign]

[Date will be recorded automatically]

Provider / Witness

provider_name

[Electronic signature will be collected via zsign]

[Date will be recorded automatically]