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Authorization To Release Healthcare Information

This document authorizes the release of a patient's healthcare information from [Doctor Name] to another party. It includes the patient's name, date of birth, social security number, and specifies what information can be released, such as all healthcare records, treatment for specific conditions, or records related to drug, alcohol, or mental health. The patient must sign and date the document to authorize the release for up to 90 days.

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Sourire Rhya
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30 views1 page

Authorization To Release Healthcare Information

This document authorizes the release of a patient's healthcare information from [Doctor Name] to another party. It includes the patient's name, date of birth, social security number, and specifies what information can be released, such as all healthcare records, treatment for specific conditions, or records related to drug, alcohol, or mental health. The patient must sign and date the document to authorize the release for up to 90 days.

Uploaded by

Sourire Rhya
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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[Doctor Name]

[Doctor Name]
[Doctor Name]
[Doctor Name]
[Doctor Name]
[Doctor Name]
[Doctor Name]
[Street Address], [City, ST ZIP Code]
Phone: [Phone Number] Fax: [Fax Number]

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

Patient’s Name: Date of Birth:

Previous Name: Social Security #:

I request and authorize to


release healthcare information of the patient named above to:

Name:

Address:

City: State: Zip Code:

This request and authorization applies to:

 Healthcare information relating to the following treatment, condition, or dates:

 All healthcare information

 Other:

Definition: Sexually Transmitted Disease (STD) as defined by law, RCW 70.24 et seq., includes herpes, herpes
simplex, human papilloma virus, wart, genital wart, condyloma, Chlamydia, non-specific urethritis, syphilis, VDRL,
chancroid, lymphogranuloma venereuem, HIV (Human Immunodeficiency Virus), AIDS (Acquired
Immunodeficiency Syndrome), and gonorrhea.

 Yes  No I authorize the release of my STD results, HIV/AIDS testing, whether negative or positive, to
the person(s) listed above. I understand that the person(s) listed above will be notified that I
must give specific written permission before disclosure of these test results to anyone.

 Yes  No I authorize the release of any records regarding drug, alcohol, or mental health treatment to
the person(s) listed above.

Patient Signature: Date Signed:

THIS AUTHORIZATION EXPIRES NINETY DAYS AFTER IT IS SIGNED.

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