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Records Office · {{ practice_phone }} · Fax {{ practice_fax }} · {{ practice_email }}
{{ form_no }} Form HIM-3 (Rev. 2026)
Date issued {{ issue_date }}

Authorization for Release of Protected Health Information

45 CFR §164.508
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Patient InformationThe individual whose health records are being released
Patient full name
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Date of birth
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Medical record no.
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Address on file
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Phone
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Release DirectionWho is authorized to release these records, and who may receive them
I authorize this provider to RELEASE
Provider / facility
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Address
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Phone / fax
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to DISCLOSE my records to
Recipient / facility
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Address
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Phone / fax
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Records to be ReleasedCheck each category authorized for disclosure. Cardiology-relevant records are highlighted.
Laboratory resultsCardiacLipid panels, troponin, BNP, metabolic panels
Imaging & diagnosticsCardiacEKG, echocardiogram, stress test, chest imaging
Office visit & progress notesEncounter notes, assessments, plans of care
History & physicalProblem list, surgical and family history
Medication listCurrent and discontinued prescriptions
Immunization recordVaccination history and dates
Other (specify):{{ records_other }}
Date range of records {{ date_from }}through{{ date_to }} or all available records
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Purpose & Delivery
Purpose of disclosure
Continuing care / referral Second opinion Personal use Other
Specific reason
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Deliver records by
Secure electronic / portal Fax Mail Picked up in person
Deliver to (if different)
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Expiration
This authorization expires {{ expiration }}, or on the earlier date or event I write here: {{ expire_event }}. If no date is given, it expires one year from signing.
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Your Rights & Consent

Please read carefully before signing

  1. You may revoke this authorization at any time by writing to the Records Office above. Revoking it stops future disclosures but does not undo any release already made in reliance on it.
  2. Your care is not conditioned on signing. Cedar Ridge Family Medicine may not refuse treatment, payment, or eligibility for benefits because you decline to sign — except where the records are needed solely to create them for a third party.
  3. Re-disclosure caution. Once your records are released to the recipient named above, federal privacy law (HIPAA) may no longer protect them, and the recipient could share them further.
  4. A copy is as valid as the original, and you are entitled to a copy of this signed authorization.
I have read and understand this authorization. I am signing it freely and voluntarily, and I authorize the release of the records I have marked above for the purpose I have stated.
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Signature
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Signature of patient
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Date
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Printed name
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Patient date of birth
Complete the line below only if you are signing on behalf of the patient as a personal representative (parent, guardian, or holder of a health-care power of attorney).
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Signature of personal representative
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Relationship / authority to act
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Date
{{ practice_name_foot }} · Health Information Management Authorization to Disclose PHI · Form HIM-3 · Page 1 of 1