Medical Records Release Form

Authorization to Release Medical Information This form authorizes the release of your protected health information (PHI) in accordance with the Health Insurance Portability and Accountability Act (HIPAA). Your health information is confidential and will not be disclosed without your written authorization except as permitted or required by law. Please complete all fields below to specify what information you would like released, to whom, and for what purpose. You have the right to revoke this authorization at any time by submitting a written request to our office. Revocation will not affect any disclosures already made in reliance on your prior authorization.

I understand that I have the right to revoke this authorization at any time by providing written notice to the practice, and that revocation will not apply to information already released.