Authorization for Release of Protected Health Information

Patient Name: {{PATIENT_NAME}}

Date of Birth: {{DOB}}

Address: {{PATIENT_ADDRESS}}

Phone: {{PHONE}}

Email: {{EMAIL}}

2. I Authorize the Following to Release My Records

Provider/Facility: {{PROVIDER_NAME}}

Address: {{PROVIDER_ADDRESS}}

3. Release My Records To

Recipient: {{PATIENT_NAME}} (myself)

Address: {{PATIENT_ADDRESS}}

Email: {{EMAIL}}

4. Information to Be Released

Complete Electronic Health Information (EHI) Export

All associated documents and images

See Appendix A (attached) for a detailed description of the specific export requested and instructions for producing it.

5. Purpose

Personal / At the request of the individual

See Appendix A for additional detail.

6. Expiration

This authorization expires one year from the date of signature, or upon fulfillment of the request, whichever comes first.

7. Patient Rights

I understand that I may revoke this authorization at any time by submitting a written request, except to the extent that action has already been taken in reliance on it. I understand that information disclosed pursuant to this authorization may be subject to re-disclosure and may no longer be protected by HIPAA. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on signing this authorization. A copy of this authorization is as valid as the original.