CONFIDENTIAL

Authorization for Release of Medical Records

HIPAA-Compliant Patient Authorization Form

1. Patient Information

Patient Name Jordan Lee

Date of Birth 06/22/1988

Address 420 Burnside Street, Apt 3, Portland, OR 97209

Phone (503) 555-0199

Patient ID PAT-2026-0847

SSN (last 4) 4829

2. Release To / From

Release From Sunrise Family Medicine

Release To Portland Rheumatology Associates

From Address 4200 Wellness Drive, Suite 100, Portland, OR 97201

To Address 5500 Medical Center Drive, Suite 302, Portland, OR 97239

3. Records Requested

Complete medical records including lab results, imaging, and physician notes

Date Range January 1, 2024 to April 10, 2026

Format Electronic (via secure fax or health information exchange)

4. Purpose of Disclosure

Purpose

Continuity of care — referral to rheumatology specialist

Authorization Expires October 10, 2026

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

April 10, 2026

Printed Name

Jordan Lee

Relationship (if representative)

Self