Authorization to Release Healthcare Information Form

Patient’s Name *

Date of Birth *

Previous Name(s)

Social Security #

I request and authorize *

to release healthcare information of the patient named above to:

Name *

Street Address *

City

State/Province

ZIP / Postal Code

Phone *

Fax#

Federal Regulation, 42 CFR Part 2, requires that a description of the amount, the kind of information that is to be disclosed and the purpose for this disclosure.

This request and authorization applies to *All records availableAll correspondence

Please specify

and is to be released for the purpose of:Continuity of careOther: (specify)

Please specify

By checking the boxes below, I specifically authorize the voluntary release of the following types of medical records, if such records exist.

I authorize the release of my HIV/AIDS records, whether negative or positive, to the person(s) listed above. I understand that the person(s) listed above will be notified that I must give specific written permission before disclosure of these test results to anyone. *YesNo

I authorize the release of any records regarding drug, alcohol, or mental health treatment to the person(s) listed above. *YesNo

This consent to release is valid for one year, or until otherwise specified, and thereafter is invalid. Specify date, event, or condition on which permission will expire:

I understand that at any time between the time of signing and the expiration date listed above I have the right to revoke this consent at any time to the extent that information has already been released based on this authorization.

Patient Signature *

Relationship to patient *

Date Signed *