Patient Name:___________________________________________________________

Date of Birth___/___/____

Address: __________________________________________

City: _______________State:_____ Zip: __________

Email Address: ___________________________ 

Phone: _______________

Social Security #: ______ ____ _____

I request that my protected health information (PHI) from ________________________

to be disclosed to:

Recipient name: ___________________________________________________________________________

Address:____________________________________________

City:___________________State___Zip:_________

Email Address: _______________________________________________

Phone: ___________________________

Fax (healthcare provider only): ___________________________________________________________________

□ All (Complete) Medical Records
□ Partial Medical records from _________________ to _________________
□ Lab Results
□ Imaging Results
□ Other:

I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment of alcohol or drug abuse.

State and Federal Law protect the following information. If this information applies to you, please indicate if you would like this information released/obtained (include dates where appropriate):

Alcohol, Drug, or Substance Abuse Records

□ Yes   □ No   □ Dates:______________

HIV Testing and Results

□ Yes   □ No   □ Dates:______________

Mental Health or Psychotherapy Records

□ Yes   □ No   □ Dates:______________

Covering the period of health from:

□ dates   To:______________

Purpose for requesting

□ Legal  □ Insurance  □ Personal 

□ Continuation of Care  □ Other

Disclosure Format

● Requests for copies of medical records are subject to reproduction fees in accordance with federal/state regulations.

● I have the right to revoke this authorization at any time. Revocation must be made in writing and presented or mailed to the Health Information Management Department at the above address.
Revocation will not apply to information that has already been disclosed in response to this authorization.

● Unless otherwise revoked, this authorization will expire on the following date/event/condition:__________________
If I fail to specify any expiration date/event/condition, this authorization will expire one year from the date signed.

● Treatment, payment, enrollment or eligibility for benefits may not be conditioned on whether I sign this authorization.

● Any disclosure of information carries with it the potential for unauthorized redisclosure, and the information may not be protected by federal confidentiality rules.