[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-307459-105":53,"doc-detail-307459-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","authorization-to-use-and-disclose-health-information-medical-records-release-form","Authorization to Use and Disclose Health Information - Medical Records Release Form","","Authorization to use and disclose health information document enabling a person to grant a specified health care provider permission to release particular medical records to a named recipient. It defines what information can be requested and authorized, including hospital records, diagnostic imaging, laboratory, dental, continuity-of-care records, and optional categories such as HIV/AIDS, genetic testing, mental health, alcohol and drug information. It includes prohibited re-disclosure rules under federal confidentiality provisions, requires initials for sensitive categories, and sets limits for time period and worker’s compensation claims, with signature, cancellation rights, and expiration terms.",{"@graph":63,"@context":118},[64,80,101],{"@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-to-use-and-disclose-health-information-medical-records-release-form/307459/",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-to-use-and-disclose-health-information-medical-records-release-form/307459.png","ImageObject",442,249,{"name":88,"@type":89},"Mason","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-23","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":8},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What does the authorization allow the requester to do?","Question",{"text":108,"@type":109},"It allows the named facility or health care provider to release information requested to the specified recipient for the stated purpose.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"Which types of records can be released under this form?",{"text":113,"@type":109},"It lists authorized records such as hospital records (including nursing and progress notes), transcribed hospital reports, pathology reports, continuity-of-care medical records, diagnostic imaging, clinician office chart notes, laboratory reports, and dental records, plus options like emergency and urgent care records.",{"name":115,"@type":106,"acceptedAnswer":116},"How are sensitive categories like HIV/AIDS or genetic testing handled?",{"text":117,"@type":109},"They must be specifically authorized by placing initials next to the relevant category, and re-disclosure is prohibited under federal confidentiality rules (42 CFR Part 2) unless permitted.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},307459,1790557162,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":8,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":4},5909887256941,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","# AUTHORIZATION TOUSE AND DISCLOSE HEALTH INFORMATION\n\nI authorize                                                                                                                                            \n(Name and address of facility/health care provider you wish to release information)  \nTo release information requested for(either DOB or SID is REQUIRED to identify record):  \n(Name of person making request)D.O.BDate of Birth)  .I.D._  \n                     _For the purpose of                  \nTo:  \nBy INITIALING the spaces below,I specifically authorize the release of the following records,if such records exist:    All hospital records (including nursing records and progress notes)  \n  Transcribed hospital reports  Pathology reportsOther(Explain Below)  Medical records needed for continuity of care  Diagnostic imaging reports    Most recent five year history    Clinician Office Chart notes    Laboratory reports    Dental records  \n##     Emergency and Urgency care records\n\n    Please send the entire medical records(All information)to the above named recipient  \nI authorize the information listed below to be used,disclosed,or received by placing my INITIALS next to theinformation:  \n    *HIV/AIDS-related records(Copies will not be released to inmates while incarcerated)    *Genetic testing information  \n  _*Mental Health-list specific info requested  \n                               \n      **Alcohol and Drug information  \n**PROHIBITED RE-DISCLOSURE:This information has been disclosed to you from records protected by Federal Confidentiality Rules(42 CFR Part 2)|The federal rules prohibit you from making any further disclosure of this information without the specific riten consent of the person to whom it pertains or|las otherwise permitted by 42 CFR Part 2.Ageneral authorization for the release of medical or other information is NOT sufficient for this purpose     \n*Must be initialed to be included in other documents.Records will not be released without your initials specifying thatyou have granted this specific release authority.  \nThis authorization is limited to the following time period:                                                      \nThis authorization is limited to a worker's compensation claim injuries of:                                          \nMy signature indicates that I authorize the disclosure of the above information and understand the following:  \nI understand that I may choose not to sign this authorization and that my choice not to sign willnot be a basis to affect myability to obtain treatment or my eligibility for health care benefits.  \nI understand I can cancel permission to use and disclose my information at any time in writing.The only exception is whenaction has been taken in reliance on the authorization.Unless revoked earlier,this consent willexpire 180 days from the dateof signing,or shall remain in effect for the period reasonably needed to complete the request.  \nI understand this change will not affect information that has already been shared.  \nI understand that federal and state law protects my health information.However,my information could be shared withagencies or businesses that may not be covered by this law.They could then share my information with others.I understandthat they cannot share information regarding HIV/AIDS,mental health treatment,alcohol and drug treatment or genetictesting unless Igive them permission by initialing this permission above or as otherwise permitted by law.  \nDate)  \nDate)","cbCaiihKCpYDJiPt","https://ap.wps.com/l/cbCaiihKCpYDJiPt","pdf",122183,"English","# Authorization details\n## Record categories authorized\n## Sensitive information requiring initials\n## Prohibited re-disclosure rules\n## Time limits, signature, and cancellation","[{\"question\":\"What does the authorization allow the requester to do?\",\"answer\":\"It allows the named facility or health care provider to release information requested to the specified recipient for the stated purpose.\"},{\"question\":\"Which types of records can be released under this form?\",\"answer\":\"It lists authorized records such as hospital records (including nursing and progress notes), transcribed hospital reports, pathology reports, continuity-of-care medical records, diagnostic imaging, clinician office chart notes, laboratory reports, and dental records, plus options like emergency and urgent care records.\"},{\"question\":\"How are sensitive categories like HIV/AIDS or genetic testing handled?\",\"answer\":\"They must be specifically authorized by placing initials next to the relevant category, and re-disclosure is prohibited under federal confidentiality rules (42 CFR Part 2) unless permitted.\"}]","Authorization to Use and Disclose Health Information - Medical Records Release Form | PDF",1789849802]