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Free Fillable Authorization To Release Medical Information Generator

This is a great form. You can do a lot with it. But sometimes you want more, like instructions, examples, different formats, editable and of course attorney prepared. You can find one of those with this Authorization To Release Medical Information for just a few dollars.

Name of Patient
Address
Date of Birth
Medical Record Number
Social Security Number
NAME
Name of Provider
Address of Provider
Name of Recipient
Address of Recipient
Describe Purpose
Type and Amount of Information Disclosed
Expiration Date, Event, or Condition


We DO NOT collect or save the information you entered





HTML Authorization To Release Medical Information

AUTHORIZATION TO DISCLOSE MEDICAL INFORMATION

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Patien t Name: __________________ Medical Record #_______________

Address: ______________ Social Security #: _______________

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D ate of Birth : _______________

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I ____________________ ____________ ____________ (name and address) hereby authorize _____________________ __________ _______________ (name and address of provider) to disclose certain specific health information from the records of the above-named Patie nt to the following individual or organization ___________ ______________ _______ (n ame and a ddress of r ecipient ) for the following purposes:

_______________________ _________________ _________________________

_________________________

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The specific information type and amount to be used or disclosed is as follows:

______________________ ____________________ ___ __________________________ .

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I understand that the information to be released or disclosed may include information relating to sexually transmitted disease, acquired immunodeficiency syndromes (AIDS) or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse.

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I understand I may revoke this authorization at any time by giving in writing. I further understand the revocation will not apply to information that has already been released in response to this authorization.

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I also understand that u nless otherwise revoked, this authorization will expire on the following date, event or condition: _________________________ . If I fail to specify an expiration date, event or condition, this authorization will expire in 90 days. I further understand that any action taken in pursuance of this authorization prior to this expiration date is legal and binding.

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I understand why I have been asked to disclose the patients health information and I am aware of the risks and benefits of consenting or refusing to consent to the disclosure of patients health information. I hereby release the provider , its employees, officers, and physicians from any legal responsibility or liability arising from disclosure of the above information to the extent indicated and authorized herein.

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I understand that my authorization to disclose the health information hereunder is voluntary and I can refuse to sign this authorization.  I need not sign this authorization form in order to receive any treatment. I understand that, once information is disclosed pursuant to this authorization, it is possible that it will no longer be protected by medical privacy laws and could be re - disclosed by the person or agency that receives it. H owever, if this information is protected by the Federal Substance Abuse Confidentiality Regulations, the recipient may not re-disclose such information without my further written authorization unless otherwise provided for by state or federal law.

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By signing, I acknowledge I have been provided a copy of this signed authorization

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_______________ Dated: ______________

Patient / guardian 

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Description

This Authorization to Disclose and Release Medical Information template and sample can be used to disclose specific health information type and amount for a limited purpose. An expiration date can be specified and this authorization can be revoked at any time in writing.







Instructions

Simply fill out the fields on this page with the required information. Press the "Create Form" button. If you want a blank form, leave the fields as they are and click on the 'Create Form' button. On the next page you will be able to download your completed form. The form can then be edited further or just printed. That's all there is too it. We do not collect or save any of the information you enter in these forms. The information is solely used to fill out the form you are preparing.

Disclaimer: This form was not drafted by an attorney and is provided "As-Is" and may need substantial modifications to be valid. It should not be used as a legal document. By using any form on this site you agree that you are using them at your own risk.