Medical Records Release Authorization for Release of Medical Information
1. Patient Information I hereby authorize the release of my medical records from the healthcare facility or provider identified below. This authorization is made voluntarily and I understand I may revoke it at any time in writing.
2. Records to Be Released I authorize the release of the following records: complete medical records, laboratory results, diagnostic imaging, treatment notes, and/or specific records as indicated below for the date range specified.
3. Recipient Information The records shall be released to the person or organization identified below. I understand that once my health information is disclosed, it may no longer be protected by federal privacy regulations.
4. Duration and Revocation This authorization is valid for ninety (90) days from the date of signature unless otherwise specified below. I understand that I have the right to revoke this authorization in writing at any time, except where action has already been taken.
Patient Name:
Date of Birth:
Facility Name:
Records Date Range:
Recipient Name:
Patient Signature Date
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