[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-287282-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-287282-en":127},{"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":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","hipaa-compliant-authorization-for-the-release-of-patient-information-pursuant-to-45-cfr-164508","HIPAA Compliant Authorization for the Release of Patient Information Pursuant to 45 CFR 164.508","","HIPAA-compliant authorization form for releasing protected patient health information under 45 CFR 164.508. The requester identifies the covered provider/facility and patient, authorizes disclosure of complete medical records and related documentation, including clinical notes, diagnoses, imaging results, pharmacy information, billing records, and disability/Medicaid/Medicare files. The form also authorizes release of sensitive categories such as STDs, AIDS/HIV, and alcohol or drug abuse, states required compliance language for substance records, and defines representative access, revocation rights, re-disclosure terms, and expiration after two years.",{"@graph":14,"@context":73},[15,34,56],{"@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/hipaa-compliant-authorization-for-the-release-of-patient-information-pursuant-to-45-cfr-164508/287282/",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/hipaa-compliant-authorization-for-the-release-of-patient-information-pursuant-to-45-cfr-164508/287282.png","ImageObject",442,249,{"name":42,"@type":43},"Paura","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-09-23","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",6,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What information does this authorization allow to be released?","Question",{"text":63,"@type":64},"It authorizes disclosure of all protected medical information, including every page of the patient’s medical record, such as clinical notes, charts, test results, consultation records, imaging, pharmacy records, and billing information.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"Does the form allow release of sensitive health information like HIV/AIDS and substance abuse?",{"text":68,"@type":64},"Yes. It states the released information may include sexually transmitted diseases, AIDS/HIV, and alcohol or drug abuse, and authorizes release of those specific types.",{"name":70,"@type":61,"acceptedAnswer":71},"Can the authorization be revoked, and when does it expire?",{"text":72,"@type":64},"The form states the authorization may be revoked in writing at any time, except to the extent information has already been released in reliance on it. It remains in effect until two years from the date of execution, when it expires.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},287282,1789632107,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":26,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":80,"read_time":22},13056712833777,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF PATIENT INFORMATION PURSUANT TO 45 CFR 164.508  \nTO:  \n\n| Name of Healthcare Provider/Physician/Facility/Medicare Contractor |\n| --- |\n| Street Address |\n\nCity, State and Zip Code  \nRE: Patient Name:   Date ofBirth:   Social Security Number:    \nI authorize and request the disclosure of all protected information for the purpose of review and evaluation in connection with a legal claim. I expressly request that the designated record custodian of all covered entities under HIPAA identified above disclose full and complete protected medical information including the following:  \nAll medical records, meaning every page in my record, including but not limited to: office notes, face sheets, history and physical, consultation notes, inpatient, outpatient and emergency room treatment, all clinical charts, r ports, order sheets, progress notes, nurse's notes, social worker records, clinic records, treatment plans, admission records, discharge summaries, requests for and reports of consultations, documents, correspondence, test results, statements, questionnaires/histories, correspondence, photographs, videotapes, telephone messages, and records received by other medical providers.  \nAll physical, occupational and rehab requests, consultations and progress notes.  \nAll disability, Medicaid or Medicare records including claim forms and record of denial of benefits.  \nAll employment, personnel or wage records.  \nAll autopsy, laboratory, histology, cytology, pathology, immunohistochemistry records and specimens; radiology records and films including CT scan, MRI, MRA, EMG, bone scan, myleogram; nerve conduction study, echocardiogram and cardiac catheterization results, videos/CDs/films/reels and reports.  \nAll pharmacy/prescription records including NDC numbers and drug information handouts/monographs.  \nAll billing records including all statements, insurance claim forms, itemized bills, and records of billing to third party payers and payment or denial of benefits for the period   to   .  \nI understand the information to be released or disclosed may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human  \nimmunodeficiency virus (HIV), and alcohol and drug abuse. I authorize the release or disclosure of this type of information.  \nThis protected health information is disclosed for the following purposes:    \n\n| This authorization is given in compliance with the federal consent requirements for release of alcohol or substance abuse records of 42 CFR 2 .31, the restrictions of which have been specifically considered and expressly waived.\u003Cbr>You are authorized to release the above records to the following representatives of defendants in the above-entitled matter who have agreed to pay reasonable charges made by you to supply copies of such records:\u003Cbr>Name of Representative\u003Cbr>[Jennifer Harmon-jharmon@gfalls.wednet.edu](Jennifer Harmon-jharmon@gfalls.wednet.edu)\u003Cbr>Human Resources Director-Granite Falls School District\u003Cbr>Representative Capacity ([e.g. attorney](e.g. attorney), records requestor, agent, etc.)\u003Cbr>205 N Alder\u003Cbr>Street Address\u003Cbr>Granite Falls, WA 9825 |\n| --- |\n| City, State and Zip Code\u003Cbr>I understand the following: See CFR §164 .508(c)(2)(i-iii)\u003Cbr>a. I have a right to revoke this authorization in writing at any time, except to the extent information has been released in reliance upon this authorization.\u003Cbr>b. The information released in response to this authorization may be re-disclosed to other parties.\u003Cbr>c. My treatment or payment for my treatment cannot be conditioned on the signing of this authorization.\u003Cbr>Any facsimile, copy or photocopy of the authorization shall authorize you to release the records requested herein. This authorization shall be in force and effect until two years from date of execution at which time this authorization expires.\u003Cbr>Signature of Patient or Legally Authorized Representative Dat","cbCaism7b1HhdO0z","https://ap.wps.com/l/cbCaism7b1HhdO0z","pdf",33672,"English","# Authorization Overview\n## Disclosed Information Categories\n## Sensitive Information Consent\n## Authorized Recipients and Compliance Language\n## Rights, Re-disclosure, Revocation, and Expiration\n## Signatures and Dates","[{\"question\":\"What information does this authorization allow to be released?\",\"answer\":\"It authorizes disclosure of all protected medical information, including every page of the patient’s medical record, such as clinical notes, charts, test results, consultation records, imaging, pharmacy records, and billing information.\"},{\"question\":\"Does the form allow release of sensitive health information like HIV/AIDS and substance abuse?\",\"answer\":\"Yes. It states the released information may include sexually transmitted diseases, AIDS/HIV, and alcohol or drug abuse, and authorizes release of those specific types.\"},{\"question\":\"Can the authorization be revoked, and when does it expire?\",\"answer\":\"The form states the authorization may be revoked in writing at any time, except to the extent information has already been released in reliance on it. It remains in effect until two years from the date of execution, when it expires.\"}]","HIPAA Compliant Authorization for the Release of Patient Information Pursuant to 45 CFR 164.508 | PDF"]