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Medical Records Release Authorization Form (English)

Medical Records Release Authorization Form (English) 2025

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This document is an authorization form for the disclosure and use of health information by MarinHealth Medical Center. It outlines the patient's consent to release specific medical information, including mental health treatment and HIV test results, to designated individuals or entities. The form details the purpose of the release, expiration of authorization, patient rights regarding revocation and inspection of records, and legal protections concerning the confidentiality of health information.

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Versions	Form popularity	Fillable & printable
2016	4.7 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 must be on the authorization form for the release of patient?

Content for a valid authorization includes: The name of the person or entity authorized to make the request (usually the patient) The complete name of the person or entity to receive the protected health information (PHI) A specific description of the information to be used or disclosed, including the dates of service.

How do I write a letter of request for medical records?

I was treated in your office [at your facility] between [fill in dates]. I request copies of the following [or all] health records related to my treatment. [Identify records requested (e.g., medical-history form you filled out; physician and nurses notes; test results; consultations with specialists; referrals).]

What to write on a medical release form?

Patient information. Whose health records do you want? Clinic, hospital, care provider. Who has the information you want? Date of Services. Who has the information you want? Information to be released. Receiving party or destination of records. Purpose of release. Expiration date or duration of consent. Release instructions.

Does a HIPAA authorization form need to be notarized?

478-Does the Privacy Rule require that an authorization be notarized or include a witness signature. The Privacy Rule does not require that a document be notarized or witnessed.

How to write an authorization to release medical records?

I, the undersigned, authorize the release of, or request access to the information specified below from the medical record(s) of the above name patient. I understand that my records are confidential and cannot be disclosed without my written authorization, except when otherwise permitted by law.

What is a signed medical release form?

A medical records release form is a document that authorizes the release of patient health information from one healthcare provider to a requestor.

What is the best way to request the release of medical information?

You may have to fill out a form called a health or medical record release form, or request for accesssend an email, or mail or fax a letter to your provider. But a provider cannot impose unreasonable barriers to your access, or unreasonably delay you from getting your records.

Medical Records Release Authorization Form (English) 2025

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