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It lists requested record categories, the sites/providers that maintain the information, the purpose for disclosure, and the authorization’s expiration window. The form explains patient rights to refuse, revoke, and limits on protections and further redisclosure under federal privacy laws, including HIPAA and 42 CFR Part 2.",{"@graph":63,"@context":111},[64,80,102],{"@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":41,"@type":70,"position":76},"https://docshare.wps.com/template/letters/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/medical-records-release-authorization-form/288953/",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/medical-records-release-authorization-form/288953.png","ImageObject",442,249,{"name":88,"@type":89},"Connor ","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-08","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",9,{"@type":103,"mainEntity":104},"FAQPage",[105],{"name":106,"@type":107,"acceptedAnswer":108},"Can the patient revoke the authorization?","Question",{"text":109,"@type":110},"Yes. 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Box 751  \nHulbert, OK 74441  \nPhone: (918) 772-3390 | Fax: (918) 772-3638  \n\n| Patient Name: | Last | First |  | Middle |\n| --- | --- | --- | --- | --- |\n| Address: | Street Address | City | State | Zip |\n\nTelephone Date of Birth Social Security Number Treatment Date(s)  \nI hereby authorize NeoHealth and its duly authorized agents and employees to  \n☐ RELEASE  OR ☐ OBTAIN  \nthe protected health information indicated below to/from:  \nName:   Phone Number:    \nAddress:  \n____________________________________________________________________________________________________________________________  \nStreet Address City State Zip  \n\n| Requested Information:\u003Cbr>I authorize the disclosure of the following types of records from   to   |  |\n| --- | --- |\n| ☐ Patient History\u003Cbr>☐ Information created or received from other Providers\u003Cbr>Specify:  ☐ Hospital & Consulting Physician Summaries\u003Cbr>☐ Billing Records\u003Cbr>☐ Entire Designated Record Set | ☐ Shot Records Only\u003Cbr>☐ Lab Reports\u003Cbr>☐ X-Rays\u003Cbr>☐ Radiology Reports\u003Cbr>☐ Pathology Reports\u003Cbr>☐ Other:   |\n| The requested information is/was maintained or created by the following sites/providers:\u003Cbr>Name of Physician or Provider Department Clinic Location\u003Cbr>_____________________________________ _____________________________________ _____________________________________\u003Cbr>_____________________________________ _____________________________________ _____________________________________\u003Cbr>*Note: Unless you are a provider, you will be charge $1.00 for the first page and $0.50 per page thereafter for paper records, $5.00 per film copied for radiology films, and postage. |  |\n\nPurpose of the Requested Use or Disclosure:  \n☐ At the Request of the Patient ☐ Other (Indicate Specific Reason)    \nExpiration Date:  \nThis Authorization Will Expire on: ☐   OR ☐ When the Following Event Occurs:    \n(Not to Exceed 6 Months From the Date of This Request)  \n\n| Your Rights: You may refuse to sign this authorization. Your refusal will not affect your ability to obtain treatment or payment.\u003Cbr>1. If the persons or entities authorized to receive this information are not healthcare providers or health plans covered by federal health privacy laws, they may re-disclose the information and those laws would no longer protect the disclosed health information.\u003Cbr>2. Once you sign this authorization, we can rely on it until you revoke it, or if you have not revoked it, until it expires. You can revoke this authorization by:\u003Cbr>Mailing a signed and dated letter to: Or in Person at:\u003Cbr>Crystal Steed Crystal Steed\u003Cbr>NeoHealth COO NeoHealth COO\u003Cbr>P.O. Box 751 129 E Main St.\u003Cbr>Hulbert, OK 74441 Hulbert, OK 74441\u003Cbr>3. The information authorized for release may include records which indicate the presence of a communicable or venereal disease which may include, but are not limited to, diseases such as Hepatitis, Syphilis, Gonorrhea, and the Human Immunodeficiency Virus, also known as Acquired Immune Deficiency Syndrome (AIDS) .\u003Cbr>4. I understand that the records requested may be protected under 42C.F.R. Part 2, governing Alcohol and Drug Abuse patient records, the Health Insurance |\n| --- |\n| Portability and Accountability Act of 1996 (“HIPAA”), 45 C. F. R Parts 160 and 164, state laws and regulations regarding the confidentiality of medical records, |\n| and cannot be release without my consent unless otherwise provided by applicable law. I understand also that state and federal laws and regulations prohibit any further disclosure of such records without my specific written consent, or when otherwise permitted by law.\u003Cbr>5. ☐ If checked, we will receive compensation for our use/disclosure of the information that is the subject of this authorization. |\n\nSignature (Patient or Legal Representative:   Date:    \nCapacity of Legal Representative * (if applicable):   *To provide verification of representative status.","cbCaie9lJZxHrpst","https://ap.wps.com/l/cbCaie9lJZxHrpst","pdf",198520,"English","# Patient Information\n# Authorization Details\n## Requested Information\n## Purpose and Expiration\n# Patient Rights and Revocation\n# Signatures and Representative Status","[{\"question\":\"Can the patient revoke the authorization?\",\"answer\":\"Yes. The patient can revoke it by mailing a signed and dated letter or by revoking in person, as listed on the form.\"}]","Medical Records Release Authorization Form | PDF",1789634280]