[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-287287-105":3,"detail-sidebar-cat-1-en-105":80,"doc-detail-287287-en":126},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":73,"head_meta":75,"extra_data":77,"updated_unix":79},105,"en","authorization-to-release-medical-information-form","Authorization to Release Medical Information - form","","Authorization to Release Medical Information form used to permit disclosure of protected health information to specified recipients. The patient or authorized representative selects the categories of records to release, provides delivery destination details, and states the purpose such as medical care, insurance, or other. The form explains rights and limitations, including voluntary consent, revocation before release, potential re-disclosure by recipients, special handling for HIV-related information, and additional compliance requirements for substance abuse or mental health notes. It also sets expiration and requires signatures and date information.",{"@graph":14,"@context":72},[15,34,55],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/authorization-to-release-medical-information-form/287287/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/authorization-to-release-medical-information-form/287287.png","ImageObject",442,249,{"name":42,"@type":43},"Oliver Hayes","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-09-24","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":26},"InteractionCounter",{"@type":54},"ViewAction",{"@type":56,"mainEntity":57},"FAQPage",[58,64,68],{"name":59,"@type":60,"acceptedAnswer":61},"What protected health information can be released using this authorization?","Question",{"text":62,"@type":63},"The form allows selection of office notes, pathology reports, radiology reports, and laboratory reports, and can include other specified records. It may also authorize related categories such as alcohol/drug treatment, mental health information, and HIV-related information when the appropriate initials are placed.","Answer",{"name":65,"@type":60,"acceptedAnswer":66},"What is the purpose of the request to release medical information?",{"text":67,"@type":63},"The patient indicates the purpose, such as medical care/treatment, insurance, or other. This selection is recorded on the form.",{"name":69,"@type":60,"acceptedAnswer":70},"Can the patient revoke this authorization, and does it expire?",{"text":71,"@type":63},"Yes. The patient or authorized representative may revoke the authorization in writing before the requested information is released. The form also specifies an expiration date, either using a completed date or a default timeframe after signing.","https://schema.org",{"og:url":32,"og:type":74,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":76,"canonical":32},"index,follow",{"doc_id":78,"site_id":7},287287,1790212103,{"code":4,"msg":81,"data":82},"success",[83,88,93,98,103,108,112,117,122],{"id":84,"doc_module":22,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},11,"Presentations",90,"presentations",{"id":89,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},12,"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social 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authorize the release of the following protected health information:  \n□ Office Notes /Name of Physician.                                                      \n□ Pathology Reports  \n口  Radiology Reports  \n□ Laboratory Reports Date(s):            \nOther:                                                                                                          \nThe purpose for this request to release medical informationis:  \n□ Medical Care/Treatment  \n□ Insurance  \n□ Other(specify)                  \nSend my medical information to:  \nName:                                                    \nAddress:                                                    \nCity,State,Zip:                                      \nI understand that:  \n·By signing this form,I am authorizing the use or disclosure of protected health information as indicated above.  \n·I may refuse to sign this authorization,which will not affect my treatment or payment for health care  \n·I may revoke this authorization at any time before the information I have requested is released by providing written notice of revocation asspecified in the Notice of Privacy Practices.  \n·If the receiving party is not subject to medical records privacy laws,the information may be re-disclosed by the recipient and may no longer be  \nprotected by federal or state law.Gramercy Gynecology shall not be held liable for any consequences resulting from re-disclosure  \n·If the information to be released contains any information about HIV/AIDS an additional HIPAA release of medical information for will berequested.  \n·Alcohol or substance abuse,mental health or psychiatry notes may have additional compliance requirements that must be met before the informationcan be released.  \n·A copy of this signed form will be provided to me.  \n·Gramercy Gynecology may charge an administrative fe to cover the cost of labor,copying,and postage.The physician's office will inform me ofany charges and arrange for payment.  \n·This Authorization expires on. 11 {if date not completed /one year after signed}  \nSignature Date  \nPatient/Representative  \nIf the patient listed above is a minor or is unable to sign and you are a parent,legal guardian,or personal representative signing on behalf of thispatient,please sign above and complete the following:  \nRetain this form in the patient's medical record and provide a copy to the patient.  \n| Patient Name   | Date of Birth   | Social Security Number   |\n| --- | --- | --- |\n| Patient Address   |  |  |\n\nI,or my authorized representative,request that health information regarding my care and treatment be released as set forth on this form:In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996(HIPAA),I understand that:  \n1.This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE,MENTAL HEALTHTREATMENT,except psychotherapy notes,and CONFIDENTIALHIV*RELATED INFORMATION only ifIplace my initials onthe appropriate line in Item 9(a).In the event the health information described below includes any of these types of information,and Iinitial the line on the box in Item 9(a),I specifically authorize release of such information to the person(s)indicated in Item 8.  \n2.If I am authorizing the release of HIV-related,alcohol or drug treatment,or mental health treatment information,the recipient isprohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law.Iunderstand that I have the right to request a list of people who may receive or use my HIV-related information without authorization.IfI experience discrimination because of the release or disclosure of HIV-related information,I may contact the New York State Di","cbCaiqruEW7qBXaf","https://ap.wps.com/l/cbCaiqruEW7qBXaf","pdf",2756865,6,8,"English","# Authorization to Release Medical Information\n## Protected Health Information to Be Released\n## Purpose of the Request\n## Recipient and Delivery Details\n## Patient Understanding, Rights, and Restrictions","[{\"question\":\"What protected health information can be released using this authorization?\",\"answer\":\"The form allows selection of office notes, pathology reports, radiology reports, and laboratory reports, and can include other specified records. It may also authorize related categories such as alcohol/drug treatment, mental health information, and HIV-related information when the appropriate initials are placed.\"},{\"question\":\"What is the purpose of the request to release medical information?\",\"answer\":\"The patient indicates the purpose, such as medical care/treatment, insurance, or other. This selection is recorded on the form.\"},{\"question\":\"Can the patient revoke this authorization, and does it expire?\",\"answer\":\"Yes. The patient or authorized representative may revoke the authorization in writing before the requested information is released. The form also specifies an expiration date, either using a completed date or a default timeframe after signing.\"}]","Authorization to Release Medical Information - form | PDF",1789632115]