Free Authorization to Disclose Health Information

AUTHORIZATION TO DISCLOSE MEDICAL INFORMATION


Patient Name: __________________ Medical Record #_______________
Address: ______________________ Social Security #: _______________
_____________________________
Date of Birth: _______________


I ____________________________________________ (name and address) hereby authorize ______________________________________________ (name and address of provider) to disclose certain specific health information from the records of the above-named Patient to the following individual or organization _____________________________________ (name and address of recipient) for the following purposes:
________________________________________________________________________
_________________________________________________________________________

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

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.

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.

I also understand that unless 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.

I understand why I have been asked to disclose the patient’s health information and I am aware of the risks and benefits of consenting or refusing to consent to the disclosure of patient’s 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.

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. However, 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.

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


______________________________________ Dated: ______________
Patient/ guardian