Authorization for Release of Medical Information

Patient Information
Authorization to release my medical records

Additional Locations

A fee for medical record copies may apply. A patient whose records are copied and sent to another healthcare provider for the purpose of continuing to receive medical care does not pay a fee for medical record copies. Requests for medical record copies for any use other than medical care will be billed. The HIPAA Privacy Rule permits healthcare providers to impose a reasonable, cost-based fee to an individual requesting a copy of medical records. The fee may only include the cost of labor, supplies and postage
Information to Release
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Disclosure of sensitive information
You have the right to refuse disclosure and prevent any other person from disclosing sensitive information related to the following conditions, treatments, or testing. Include (Indicate by checking below): Please note that the information will not be released if not checked.

Delivery Method
The purpose(s) for which disclosure is authorized (check where applicable):
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