HIPAA Form H004-2010.1

Patient Authorization for Release of Medical Records for Continuity of Care

All Fields Are Required
Last Name:  Address:
First Name:  City: 
Date of Birth:  State:
Soc. Sec. Num:
(optional)
Zip: 
Telephone:    

 

I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form. In accordance with the Health Insurance Portability and Accountability Act of 1996, as codified at 42 U.S.C. §1320d et seq. (“HIPAA”) and the Health Information Technology for Economic and Clinical Health Act of 2009 (“HITECH”), I hereby authorize my providers to RELEASE and DISCLOSE my entire medical record, including but not limited to patient histories, office notes, test results, radiology studies, pathology slides, films, referrals, consults, billing records, insurance records, records sent to you by other healthcare providers, and any other protected health information to my healthcare provider that requires these records to continue my care and provide me with treatment, review, or consultation.

Notwithstanding the statement above, I do NOT authorize the release of medical records containing any of the following checked items:

  •  Substance Abuse Information

  •  Psychiatric/Mental Health Information

  •  HIV/AIDS Information

  •  Genetic Information

This authorization is fully understood and is made voluntarily on my part. I understand that my healthcare provider may not condition treatment or payment upon execution of this authorization. However, if I refuse to sign this authorization, then my healthcare provider may not be able to obtain my medical information. I understand that the information may be redisclosed by the recipient and may no longer be protected by law. I hereby release my above listed healthcare provider and any of their HIPAA Business Associates involved in collecting my records from any legal liability that may arise out of the collection, gathering, scanning, digitizing, and release of the information requested. By signing below I express my intent to be bound by this authorization. I understand that I may revoke this authorization at any time except to the extent that action based on this authorization has been taken. Cancellation of this authorization must be made in writing and faxed to 866-920-5565. I understand that if I wish to review the Notice of Privacy Practices I may request a copy by contacting the telephone number below and one will be provided to me at no cost.

This authorization expires one (1) year from the date it has been signed.
Patient or Legal Guardian Signature (This signature has been captured electronically):

 

To sign this form electronically:  Using your mouse, hover in the shaded box area and a pen will appear.  Click and hold down on the right mouse button to sign your name.  
If you are using an IPad or cell phone, please use your finger to sign your name in the shaded box area.


A valid signature is required. Submitting this form without a valid signature may delay the patient authorization process.  Please ensure that your signature remains within the signature box.  Failure to do so may result in invalid signatures when submitted.


Date Signed: 

If Legal Guardian, please describe authority to sign:

  FOR SUPPORT CALL: 877-344-8999, OPTION 4