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The form collects patient identifiers, treatment dates, purpose, recipient/provider details, and the specific categories of records to release. It also states conditions, potential re-disclosure if the recipient is not covered, revocation steps, possible fees, and expiration timing after signature.",{"@graph":63,"@context":111},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/authorization-for-release-of-protected-health-information-medical-records-and-verbal-communication/288952/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/authorization-for-release-of-protected-health-information-medical-records-and-verbal-communication/288952.png","ImageObject",442,249,{"name":88,"@type":89},"\tJames","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-12","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",6,{"@type":103,"mainEntity":104},"FAQPage",[105],{"name":106,"@type":107,"acceptedAnswer":108},"When does the authorization expire?","Question",{"text":109,"@type":110},"The medical records release authorization expires 90 days after signature unless an earlier date is specified. 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I understand that if my records contain documentation of alcohol abuse, psychiatric condition, drug abuse or communicable diseases, this information will be released as part of my record.\u003Cbr>2. I understand that if the person or entity receiving this information is not covered by federal privacy regulations, this information will no longer be protected and may be re-disclosed.\u003Cbr>3. I understand that I may revoke this authorization/permission at any time, but revocation will not apply to information already released.\u003Cbr>• Medical Records revocations should be sent to: Lexington Health Attn: Medical Records, 2720 Sunset Blvd. , West Columbia, SC 29169.\u003Cbr>• Permission for verbal communication revocations can be done at any time by contacting Lexington Health provider/practice either in writing or in person.\u003Cbr>4. I understand that I may refuse to sign this authorization and my refusal to sign will not aff","cbCaivKnT18BAoYn","https://ap.wps.com/l/cbCaivKnT18BAoYn","pdf",72478,"English","# Authorization for Release of Protected Health Information\n## Section 1 - Medical Records Release\n## Section 2 - Verbal Communication Release\n## Section 3 - Review and Authorize","[{\"question\":\"When does the authorization expire?\",\"answer\":\"The medical records release authorization expires 90 days after signature unless an earlier date is specified. The verbal communication permission expires one year from the signature date unless previously revoked.\"}]","Authorization for Release of Protected Health Information - Medical Records and Verbal Communication | PDF",1789634277]