Patient Name Patient Birth Date Patient Address Patient Phone Number Request / Release Health Information to / from: Phone Fax Detailed description of the information to be released/received: It is completely your decision to sign this authorization form. We cannot refuse to treat you if you choose not to sign this authorization.If you sign this authorization, you can revoke it later unless we have already acted in reliance upon the authorization. If you want to revoke your authorization, send us a written or electronic note telling us that your authorization is revoked. Send this note to the office contact person listed at the top of this form.When your health information is disclosed as provided in this authorization, the recipient often has no legal duty to protect its confidentiality. In many cases, the recipient may re-disclose the information as he’/she wishes. Sometimes, state or federal law changes this possibility.I have read and understand this form. I am signing it voluntarily. I authorize the disclosure of my health information as described in this form.Signature Date If signing as a personal representative of the patient, describe the relationship to the patient and the source of authority to sign this form.Relationship to Patient Signature Note: Please allow up to 10 seconds for the form to submit.
