HIPAA Compliant Authorization Form - Authorization to Disclose Health Information - 90-Day Expiration and Revocation Instructions

Sep 17, 2026

HIPAA Compliant Authorization Form authorizes Full Range Health Services to disclose an individual’s individually identifiable health information as specified on the form. It explains the authorization is voluntary and that refusal does not affect healthcare or payment. It warns that disclosures to non-covered entities may lose federal and state privacy protection. The authorization expires 90 days after signature unless otherwise requested, and can be revoked in writing with a later signed and dated revocation.

LanguageEnglish

CategoryForms

FormatPDF

Pages1

AccessFree to download

Authorization to Disclose Health Information

Key rights and limitations

Expiration and revocation

Patient and recipient details

Purpose and information to be released

Signature and representative information

Tel: 610.241.2685 Fax: 877.732.7311 WWW.FULLRANGEHEALTH.ORG HIPAA Compliant Authorization Form AUTHORIZATION TO DISCLOSE HEALTH INFORMATION I hereby authorize Full Range Health Services to disclose my individually identifiable health information as described below. I understand that this authorization is voluntary, and I may refuse to sign this authorization. I further understand that my health care and the payment of my health care will not be affected if I do not sign this form. I understand that if the recipient authorized to receive the information is not a covered entity, [e.g. insurance](e.g. insurance) company or non-health care provider, the released information may no longer be protected by federal and state privacy regulations. I understand that this authorization will expire 90 days from the date of signature if not otherwise requested. I further understand that I may revoke this authorization at any time by notifying, in writing, Full Range Health Services where this authorization is being signed. I also understand the revocation must be signed and dated with a date that is later than the date on this authorization. The revocation will not affect any releases made prior to the receipt of the written revocation. Patient Name: Date of Birth: Street Address: Telephone Number: The information will be released to (Check off the appropriate option) Patient/Designee Attorney Other: Health Care Entity/POA Insurance Company Individual/ Organization Name: Street Address: Telephone Number: Purpose of the use and/or disclosure: 􀀀Continued Care 􀀀Legal 􀀀Insurance 􀀀Personal Use 􀀀Other: Information to be released: Include this information if applicable: 􀀀Summary Abstract only (clinic notes, history/physical, procedure reports, consultations, discharge summary) 􀀀Complete Chart 􀀀Medication 􀀀Provider Orders (DME) 􀀀Billing Record 􀀀History/Physical 􀀀Progress Note(s) 􀀀Other: I understand the record might not be complete, if it is a recent visit, and additional documentation could be added after submitting this request. Signature of Patient or Legal Representative (electronic signatures not acceptable) Date Printed Name of Patient or Legal Representative Relationship to Patient Representative’s Authority to Act ffor Patient (attach supporting documentation)

FAQs

Is signing the authorization voluntary, and will refusal affect care or payment?

Yes. Signing is voluntary, and healthcare and payment will not be affected if the form is not signed.

When does the authorization expire?

The authorization expires 90 days from the date of signature unless another request is made.

How can the authorization be revoked, and does revocation affect prior disclosures?

Revocation must be made in writing to Full Range Health Services, signed and dated with a later date than the original authorization. Revocation does not affect releases made before receipt of the written revocation.

Sep 17, 2026

Upload by Ethan Miller