Who is filling out this form? Patient (myself)Parent of minorLegal guardianSpouse/next of kinPower of AttorneyOther representative I authorize the release of: I authorize the release of: The patient's complete health recordSome of the patient's health records Until these are released, they are protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Learn more about HIPAA. I DO NOT authorize the release of: I DO NOT authorize the release of: Mental health treatment recordsCommunicable disease (HIV/AIDS) recordsDrug/alcohol abuse treatment recordsGenetic testing recordsOther Describe: I authorize the following person/organization to release the records: Name the person or organization in possession of the HIPAA-protected health information. Who will be receiving the records? Name the person or organization you're granting access to the records via this release form. This authorization will expire: This authorization will expire: when revoked in writingafter a specific eventon a specific date Describe the event: Patient's name: Patient's date of birth: What's your name? I understand I must attach proof of authorization to this form. Authorization goes into effect: Usually today's date. Next Save Save and finish later
