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The document is a 'Request for Access to/Authorization for Use and Disclosure of Protected Health Information' form from SSM Health Care. It allows patients to authorize the release of their protected health information to specified individuals or entities, detailing the type of access requested, the information to be disclosed, and the purpose of disclosure. The form includes sections for patient identification, method of delivery, acknowledgment of understanding regarding privacy regulations, and conditions under which the authorization can be revoked.

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Versions	Form popularity	Fillable & printable
2024	4.8 Satisfied (57 Votes)
2023	4.6 Satisfied (29 Votes)
2023	4.2 Satisfied (33 Votes)
2023	4.8 Satisfied (51 Votes)
2023	4.3 Satisfied (30 Votes)
2023	4.4 Satisfied (43 Votes)
2023	4.1 Satisfied (50 Votes)
2022	4.8 Satisfied (52 Votes)
2022	4.1 Satisfied (31 Votes)
2022	4.7 Satisfied (57 Votes)
2022	4.8 Satisfied (152 Votes)
2022	4.8 Satisfied (68 Votes)
2022	4.3 Satisfied (38 Votes)
2021	4.8 Satisfied (60 Votes)
2021	4.8 Satisfied (162 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How long is a signed authorization good for?

The patient may enter the date he/she wants the authorization to expire. The patient may enter an expiration event. The patient may enter a date range of information to be shared. If no expiration date is specified, this authorization is good for 12 months from the date signed in Section IX.

How long is a medical record release good for?

Theres no statutory time period within which a release must expire. However, under HIPAA, an authorization to release medical information must include a cutoff date or event that relates to whos authorizing the release and why the information is being disclosed.

Can I sue my doctor for not releasing my medical records?

If you believe that your doctor or other health care provider violated your health information privacy right by not giving you access to your medical record, you may file a HIPAA Privacy Rule Complaint with the U.S. Department of Health and Human Services (HHS) Office for Civil Rights.

Do medical release forms expire?

 A stand alone Medical Records Release and Authorization to Use and Disclose Health Information Form will state that this authorization does not have an expiration date (unless superceded by state or local laws).

How do I request medical records from SSM Depaul?

If you are requesting medical records as a third party or prefer to speak to someone over the phone, please call 866-394-4924 for more information and to make your request. Download and complete the Authorization for Release of Protected Patient Health Information form.

ssm medical records fax number

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Can you get medical records from 20 years ago?

Since many healthcare systems do not hold records for more than a decade, your medical information from 20+ years ago is likely to be incomplete.

When must a patient complete a medical records release form?

The authorization must be obtained before any PHI can be disclosed. Specific instances of when a HIPAA medical release form (medical records release authorization form) is required include: Prior to any disclosure of PHI to a third party for any reason other than treatment, payment, or healthcare operations.

Get the up-to-date ssm medical records release form 2025 now

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Got questions?

How long is a signed authorization good for?

How long is a medical record release good for?

Can I sue my doctor for not releasing my medical records?

Do medical release forms expire?

How do I request medical records from SSM Depaul?

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Can you get medical records from 20 years ago?

When must a patient complete a medical records release form?

ssm health medical records authorization form

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