Printable Medical Records Release Authorization Form A medical records release authorization form is a document that allows a person to disclose protected health information to a third party A patient can also request their medical records not currently in their possession
TO REQUEST RELEASE OF MEDICAL INFORMATION PLEASE COMPLETE AND SIGN THIS FORM I hereby voluntarily authorize the disclosure of information from my health record Name of Patient Patient Information Patient Name Record Number Use our Medical Records Release Authorization Form to allow the release of your medical information to yourself or anyone else who may need it Create Document Updated July 27 2023 Reviewed by Susan Chai Esq
Printable Medical Records Release Authorization Form
Printable Medical Records Release Authorization Form
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If you have questions about this authorization form or the release of your health information please contact the Stanford Health Care HIMS Department at 650 723 5721 or University Healthcare Alliance UHA HIMS Department at 510 731 2676 before signing this form SECTION I Please sign and date this form to authorize Stanford Health Care and A medical records release authorization form is a document that allows healthcare providers to share a patient s medical records with specified parties such as insurance companies or other doctors
A HIPAA release form must be obtained from a patient before their protected health information is disclosed for any purpose other than those detailed in 45 CFR 164 506 which are specifically covered in 45 CFR 164 508 and summarized below Prior to the disclosure of PHI to a third party for reasons other than the provision of treatment This authorization is given in compliance with the federal consent requirements for release of alcohol or substance abuse records of 42 CFR 2 31 the restrictions of which have been specifically considered and expressly waived
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Instructions This form is to be used by a patient or legal representative to authorize the release of information to a third party other than a family member or friend such as an insurance company employer or for legal purposes etc Print clearly each section needs to be completed to be valid 2 Additional Patient Information Paramedical facility medical examiner medical records service prescription history clearing house consumer reporting agency employer or family member to release Check one all health information about me my medical records as described on the following page Person Organization to Release Information
Q Outpatient Medical Records authorization is for psychotherapy notes it may not be combined enrollment or eligibility for benefits on the signing of this form By signing below I represent and warrant that I have authority to sign GENERAL MEDICAL RECORDS RELEASE AND AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION Authorization for Release of Protected Health Information Additional Patient Rights and Responsibilities A disclosure statement as required by law will accompany all records released Release of my records will be for the purpose stated on this form Only those items checked off or listed will be released
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A medical records release authorization form is a document that allows a person to disclose protected health information to a third party A patient can also request their medical records not currently in their possession
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TO REQUEST RELEASE OF MEDICAL INFORMATION PLEASE COMPLETE AND SIGN THIS FORM I hereby voluntarily authorize the disclosure of information from my health record Name of Patient Patient Information Patient Name Record Number
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Printable Medical Records Release Authorization Form - 1 Type of records to be released and approximate date s of service check all that apply Inpatient Emergency Dept Dates Outpatient Physician Office Clinic I authorize the release of check all that apply Mental Health Information contained in the records indicated above 2 Specific information to be released check all that apply
