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PATIENT INFORMATION FORM Patient Name Sex: Birth Date: Social ...

PATIENT INFORMATION FORM Patient Name Sex: Birth Date: Social ... 2026

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4.7 out of 5

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The document is a Health Information Release Form that authorizes Callen-Lorde Community Health Center to share a patient's identifiable health information with specified individuals or organizations. It includes sections for patient information, details on what information can be disclosed (medical and dental records), sensitive information categories (such as HIV-related and mental health treatment), the reason for the release, and the time frame for authorization. The form emphasizes the voluntary nature of signing, the right to revoke consent, and potential consequences of disclosure.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out Section 1: Patient Information. Enter your last name, first name, today's date, address, apartment number (if applicable), city, state, zip code, date of birth, and phone number.
Move to Section 2: Release Information To. Authorize the Callen-Lorde Community Health Center to share your health information by providing the organization’s name, address, city, state, zip code, phone number, and fax number.
In Section 3: Information to be Disclosed, indicate how you want the information released (fax, mail, or pick-up) and check 'Yes' or 'No' for each type of medical and dental record you wish to disclose.
Proceed to Section 4: Sensitive Information. Sign next to any categories of sensitive information you authorize for release.
Complete Section 5: Release Reason & Time Frame by specifying the reason for the release and any expiration date if different from 12 months.
Finally, sign at the bottom of the form to confirm your authorization.

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Versions	Form popularity	Fillable & printable
2019	4.7 Satisfied (25 Votes)
2011	4.2 Satisfied (31 Votes)

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

What information does a patient information form gather?

Health information is the data related to a persons medical history, including symptoms, diagnoses, procedures, and outcomes. A health record includes information such as: a patients history, lab results, X-rays, clinical information, demographic information, and notes.

What is on a patient information form?

A patient information form is used by medical practices to collect information from patients. Use this free patient information form template to collect patients contact information, insurance details, and any other information you need!

Is gender a patient identifier?

Therefore, the current recommended best practice involves asking both sex assigned at birth and current gender identity. Current gender identity, name, and pronouns should be documented and used for communication with the patient, as well as things like name bands and room assignments.

What is specific medical information pertaining to the patient such as name date of birth and Social Security number?

The Privacy Rule calls this information protected health information (PHI). Individually identifiable health information is information, including demographic data, that relates to: the individuals past, present or future physical or mental health or condition, the provision of health care to the individual, or.

What does patient information include?

Information Included in Medical Records Patient identification, contact information, and date of birth. Billing and health insurance details. List of current and chronic ailments and diagnoses. Current medications list with dosage.