[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-288949-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-288949-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":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","medical-records-release-authorization-form","Medical-Records-Release-Authorization-Form","","Authorization form for releasing and requesting a patient’s individually identifiable health information. Includes patient identifiers (name, DOB, MR number, address) and instructions for selecting the recipient and purpose of release. Allows the requester to indicate specific information types (operative report, anesthesia record, laboratory results requisitioned through SSC, and other). Requires patient or legal representative acknowledgment statements, initials, signature, printed name, relationship, and a noted 30-day expiration with the ability to revoke in writing.",{"@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/medical-records-release-authorization-form/288949/",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/medical-records-release-authorization-form/288949.png","ImageObject",442,249,{"name":42,"@type":43},"Mason","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-12","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",11,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What information does the authorization allow to be used or disclosed?","Question",{"text":63,"@type":64},"The form authorizes the use or disclosure of the patient’s individually identifiable health information as described on the form and in the selected release details.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"How does the patient indicate the purpose and recipient of the release?",{"text":68,"@type":64},"The patient checks a box for the purpose of release and identifies where the information should be sent, including city, state, zip, and fax fields.",{"name":70,"@type":61,"acceptedAnswer":71},"How long is the authorization valid, and can it be revoked?",{"text":72,"@type":64},"The authorization expires 30 days from the date it is signed. It can be revoked at any time in writing, but the revocation does not affect actions taken before the provider receives it.","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},288949,1791101745,{"code":4,"msg":82,"data":83},"success",[84,88,93,98,103,108,112,117,122],{"id":55,"doc_module":22,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},"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 Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":82,"data":127},{"doc_id":79,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":109,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":139,"read_time":4},5909887256941,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","MEDICAL RECORD RELEASE AUTHORIZATION/REQUEST  \nPatient:  DOB:   MR\\#:   \nCurrent Address:   City, State, Zip:    \nI hereby authorize the use or disclosure of my individually identifiable health information as described below. I understand that this authorization is voluntary. I understand that if my health information is used or disclosed, the released information may no longer be protected by privacy regulations issued by the federal government.  \nI authorize information to be sent to: Purpose of Release (check one box):  \n  􀂆 Referral/Consultation 􀂆 Legal Self, Physician, or Third Party Named  \n  􀂆 Personal Use 􀂆 Insurance Address  \n  􀂆 Other   City, State, Zip  \nFax  \nIndicate type of information to be released below:  \n􀂆 Operative Report 􀂆 Laboratory Results requisitioned through SSC  \n􀂆 Anesthesia Record 􀂆 Other   For the following date/(s):  , ,   \nThe patient or the patient’s representative must read and initial the following statements:  \na. I understand that my health care and payment for my health care will not be affected if I do not sign this form. Initials:    \nb. I understand that I may see and copy the information described on this form if I ask for it, and that Southington Surgery Center will give me a copy of this form after I sign it. Initials:    \nc. I understand that this authorization will expire 30 days from the date I sign this form. Initials:    \nd. I understand that I may revoke this authorization at any time by notifying Southington Surgery Center in writing, but if I do revoke it, the revocation will not have any effect on any actions Southington Surgery Center took before it received the revocation. Initials:    \ne. I understand that once released, the record custodian, or its employees have no responsibilities or liability that may arise regarding any aspect of this authorization. Initials:    \nI understand that there may be charges associated with copying my medical record and assume responsibility for these fees.  \nSignature of Patient or Patient’s Legal Representative  \nDate  \nPrinted Name of Patient or Patient’s Legal Representative Relationship to Patient","cbCaitSEtGlI727R","https://ap.wps.com/l/cbCaitSEtGlI727R","pdf",255067,"English","# Medical Record Release Authorization/Request\n## Patient and Request Details\n## Recipient and Purpose of Release\n## Type of Information and Dates\n## Patient/Representative Initial Statements\n## Signature and Date","[{\"question\":\"What information does the authorization allow to be used or disclosed?\",\"answer\":\"The form authorizes the use or disclosure of the patient’s individually identifiable health information as described on the form and in the selected release details.\"},{\"question\":\"How does the patient indicate the purpose and recipient of the release?\",\"answer\":\"The patient checks a box for the purpose of release and identifies where the information should be sent, including city, state, zip, and fax fields.\"},{\"question\":\"How long is the authorization valid, and can it be revoked?\",\"answer\":\"The authorization expires 30 days from the date it is signed. It can be revoked at any time in writing, but the revocation does not affect actions taken before the provider receives it.\"}]","Medical-Records-Release-Authorization-Form | PDF",1789634273]