Medical Records Release Authorization Form

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Medical Records Release Authorization
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Parent Permission for Records Release
I hereby give
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permission to release all records as indicated below, to
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Medical Records Release To Whom
Release Records to the following Person(s) or Organizations:
Purpose of Records Release
These records will be released for the purpose of:









 
Records Released Will Include
The records to be released will include:

 
Disclose Medical Issues Only If Checked
To be disclosed the following items must be specifically checked:





If this patient is 12 years old or older, the patient must also authoirize the release of this information:
 
Release These Medical Records
Please release only the following:




 
Date of Request
I understand that I have the right to inspect and copy the information I have authorized to be disclosed by this authorization. In the event I refuse to authorize the release of the above-described information, I understand that it will not be disclosed, except as provided by law.
I understand that the practice may not condition treatment on whether I sign this authorization, except when the provision of healthcare is solely for the purpose of creating protected health information for disclosure to a third party.
I understand that this authorization is valid for one full year unless a written letter of termination is received.
I understand that I may revoke this authorization at any time by giving written notice to the physician of my designer to do so. I also understand that I will not be able to revoke this authorization in cases where the physician has already relied on it to use or disclose my health information. Written revocation must be sent to the physician's office. Absent such revocation, the Authorization of Release of Confidential Health Information will terminate on
 
Parent Signature
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