CONFIDENTIAL

Authorization for Release of Medical Records

HIPAA-Compliant Patient Authorization Form

1. Patient Information

Patient Name {{ patient_name }}

Date of Birth {{ patient_dob }}

Address {{ patient_address }}

Phone {{ patient_phone }}

Patient ID {{ patient_id }}

SSN (last 4) {{ patient_ssn_last4 }}

2. Release To / From

Release From {{ release_from_name }}

Release To {{ release_to_name }}

From Address {{ release_from_address }}

To Address {{ release_to_address }}

3. Records Requested

Date Range {{ records_date_from }} to {{ records_date_to }}

Format {{ records_format | default("Paper / Electronic") }}

4. Purpose of Disclosure

Purpose

Authorization Expires {{ expiration_date }}

I understand that I have the right to revoke this authorization at any time by providing written notice to the organization listed above. I understand that revocation will not apply to information that has already been released. I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected under HIPAA. I understand that treatment, payment, enrollment, or eligibility for benefits cannot be conditioned on signing this authorization unless required for research-related treatment.

Patient / Authorized Representative

Signature

Date

Printed Name

Relationship (if representative)