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Authorization for release of health information - Montefiore Nyack 2025

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The document is an authorization form from Montefiore Nyack Hospital allowing the release of a patient's health information. It requires the patient's details, specifies the records to be released, and outlines the rights of the patient regarding revocation of consent. The form includes sections for designating recipients of the information, such as the patient, an attorney, or another individual. It also addresses specific types of sensitive information that may be disclosed and provides contact information for the hospital's Health Information Services.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the patient's name, date of birth, and telephone number in the designated fields.
Specify who will receive the records by filling out either the patient, attorney, or other individual/company section. Ensure you provide complete contact details including address and email.
Indicate which medical records you wish to release by checking the appropriate boxes for ER, inpatient, outpatient records, images, or billing. If specific documents are needed, list them clearly.
Read and complete the authorization expiration section. Enter a date if applicable and provide your initials.
Sign and date the form at the bottom. If applicable, include signatures from a parent or guardian.

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Versions	Form popularity	Fillable & printable
2022	4.6 Satisfied (58 Votes)
2021	4.2 Satisfied (66 Votes)

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How to fill out an authorization for release of health information?

Begin by specifying your name, the entity authorized to disclose information, and the individuals or entities you authorize to receive it. Indicate the specific information and purpose for which it will be disclosed, add an expiration date or event, and sign and date the form to confirm your consent.

What requires an authorization to release protected health information (PHI)?

If a HIPAA Authorization Form lacks the core elements or required statements, if it is difficult for the individual to understand, or if it is completed incorrectly, the authorization will be invalid and any subsequent use or disclosure of PHI made on the reliance of the authorization will be impermissible.