UNIVERSAL PATIENT AUTHORIZATION FORM FOR FULL DISCLOSURE OF HEALTH INFORMATION - FOR TREATMENT AND QUALITY OF CARE - Read Entire Form Before Signing

Sep 17, 2026

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Universal Patient Authorization Form for Full Disclosure of Health Information authorizes a patient (or legal representative) to permit the use and disclosure of all health information to specific persons or organizations for treatment and related quality-of-care purposes. The authorization outlines what information is included, which sources may disclose it, and who may receive it, including sensitive conditions. It defines the effective period, the patient’s right to revoke by written notice, and notes limits and circumstances where information may be redisclosed.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Patient Authorization Overview

Patient Information and Coverage

What Information Is Included

From Whom Information Comes

To Whom Information May Be Disclosed

Purpose and Effective Period

Revocation and Copy Authorization

Form Details and Legal Notes

UNIVERSAL PATIENT AUTHORIZATION FORM FOR FULL DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT AND QUALITY OF CARE ***PLEASE READ THE ENTIRE FORM, BOTH PAGES, BEFORE SIGNING BELOW*** Patient (name and information of person whose health information is being disclosed): Name (First Middle Last): Date of Birth (mm/dd/yyyy): Address: City: State: Zip: You may use this form to allow your healthcare provider to access and use your health information. Your choice on whether to sign this form will not affect your ability to get medical treatment, payment for medical treatment, or health insurance enrollment or eligibility for benefits. By signing this form, I voluntarily authorize, give my permission and allow use and disclosure: OF WHAT: ALL MY HEALTH INFORMATION including any information about sensitive conditions (if any) [See page 2 for details] FROM WHOM: ALL information sources [See page 2 for details] TO WHOM: Specific person(s) or organization(s) permitted to receive my information (must be a healthcare provider): Person/Organization Name: Phone: ( ) Address: Fax: ( ) PURPOSE: To provide me with medical treatment and related services and products, and to evaluate and improve patient safety and the quality of medical care provided to all patients. EFFECTIVE PERIOD: This authorization/permission form will remain in effect until my death or the day I withdraw my permission. REVOKING MY PERMISSION: I can revoke my permission at any time by giving written notice to the person or organization named above in “To Whom.” In addition: 􀁸 I authorize the use of a copy (including electronic copy) of this form for the disclosure of the information described above. 􀁸 I understand that there are some circumstances in which this information may be redisclosed to other persons [See page 2 for details] . 􀁸 I understand that refusing to sign this form does not stop disclosure of my health information that is otherwise permitted bylaw without my specific authorization or permission. 􀁸 I have read all pages of this form and agree to the disclosures above from the types of sources listed. X Signature of Patient or Patient’s Legal Representative Date Signed (mm/dd/yyyy) Print Name of Legal Representative (if applicable) Check one to describe the relationship of Legal Representative to Patient (if applicable): 􀂇 Parent of minor 􀂇 Guardian 􀂇 Other personal representative (explain: ) NOTE: This form is invalid if modified. You are entitled to get a copy of this form after you sign it. Form Florida AHCA FC4200-004 (July 1, 2011) Page 1 of 2 59B-16 .002, F.A.C. [www.FHIN.net](www.FHIN.net) Explanation of Form Florida AHCA FC4200‐004 “Universal Patient Authorization for Full Disclosure of Health Information for Treatment & Quality of Care” Laws and regulations require that some sources of personal information have a signed authorization or permission form before releasing it. Also, some laws require specific authorization for the release of information about certain conditions and from educational sources. “Of What”: includes ALL YOUR HEALTH INFORMATION, INCLUDING: 1. All records and other information regarding your health history, treatment, hospitalization, tests, and outpatient care. This information may relate to sensitive health conditions (if any), including but not limited to: a. Drug, alcohol, or substance abuse b. Psychological, psychiatric or other mental impairment(s) or developmental disabilities (excludes “psychotherapy notes” as defined in HIPAA at 45 CFR 164.501) c. Sickle cell anemia d. Birth control and family planning e. Records which may indicate the presence of a communicable disease or noncommunicable disease; and tests for or records of HIV/AIDS or sexually transmitted diseases or tuberculosis f. Genetic (inherited) diseases or tests 2. Copies of educational tests or evaluations, including Individualized Educational Programs, assessments, psy

FAQs

Who can sign this authorization form?

The patient signs, or the patient’s legal representative may sign if applicable. The form includes a check for the representative’s relationship to the patient.

What health information does “full disclosure” include?

It includes all health information, including records about health history, treatment, hospitalization, tests, outpatient care, and sensitive conditions such as substance abuse, mental impairment, genetic diseases, and communicable or noncommunicable diseases, as described in the form.

How long is the authorization effective, and can it be revoked?

The authorization remains in effect until death or until the patient withdraws permission. Revocation can be made at any time by giving written notice to the person or organization named in the “To Whom” section.

Sep 17, 2026

Upload by Mia