Medical Records Release Authorization Template

  • HIPAA Authorization Form

  • Name
    First NameLast Name
  • Date of Birth
    Pick a DateDate
  • Date From
    Pick a DateDate
  • Date To
    Pick a DateDate
  • Allowed Purpose of Disclosure of Information
    Indicate the purpose of disclosure (e.g. For research, for sponsorships, further development of study)
  • Person Allowed to Disclose Information
    PrefixFirst NameLast NameSuffix
  • Type of Medical Information to be disclosed
    All Medical RecordsAmbulatory Clinic RecordsMedical ConsultationsDental RecordsDischarge RecordsEmergency RecordsFinancial RecordsMedical History & Physical ExamsImaging ReportsLaboratory & Pathology ReportsOperation ReportsProgress NotesPsychological Tests
  • Other Information allowed to be disclosed
    I give consent to the release of my HIV/AIDS testing information if there is anyI give consent to the release of information pertaining to drugs and alcoholI give consent to the release of my genetic information and family background informationI give consent to the release of information pertaining to mental health diagnosis or treatment.
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