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Authorization of
Records Release

Please fill out the electronic form below.
If you don’t want to fill out this form electronically, click here to print a PDF version and fill it out prior to your appointment.
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    Section A: (If yes, complete the Authorization for Research Form. If no, proceed to Section B.)

    Will the Protected Health Information (PHI) be created or used for research and include treatment of the patient?

    Section B: (Required for all Authorizations for Release of PHI or Right to Access)

    Requestor: (if patient is not the requestor)

    PHI Recipient:

    PHI Sender:

    This authorization will expire on the following: (Fill in the Date or the Event, but not both.)

    Is this request for psychotherapy notes:

    (If "Yes" then this is the only item you may request on this, If "No" then you may check as many items below as you need. authorization.)

    All PHI in record

    History and Physical

    Consult Report

    Operative Report

    Progress Notes

    Physician Orders

    Laboratory

    Imaging/Radiology

    Nursing Notes

    Medication Record

    Demographics

    Rehabilitation Services

    Special Test/Therapy

    Itemized Bill/Claims

    Other

    I acknowledge, and hereby consent to such, that the released information may contain alcohol, drug abuse, psychiatric, HIV testing, HIV results or AIDS information.

     (Initial)

    I understand that:

    I may refuse to sign this authorization and my treatment will not be conditioned upon signature of this authorization (except for non-health related services such as pre-employment testing, life insurance exams, or drug screenings).

    I may revoke this authorization at any time in writing, but if I do, it will not have any affect on any actions taken prior to receiving the revocation. Further details may be found in the Notice of Privacy Practices.

    If the requester or receiver is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations and may be re-disclosed.

    I understand that I may see and obtain a copy the information described on this form, for a reasonable copy fee, if I ask for it.

    I will receive a copy of this form after I sign it.

    Section C: (Signatures)

    I have read the above and authorize the disclosure of the protected health information as stated.

    When you submit, your form will be sent to a HIPAA secure account.