Authorization to Use or Disclose Protected Health Information (PHI) - Sonora Quest 2025

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The document is an authorization form for the use or disclosure of Protected Health Information (PHI) by Sonora Quest Laboratories. It requires patient identification details, specifies delivery preferences for results, and outlines the implications of disclosing sensitive health information. The patient acknowledges understanding of the information being shared, including potential risks associated with unencrypted communication, and retains the right to revoke authorization within a specified timeframe.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out the Patient Identification section. Enter your name, date of birth, address, phone number, and any additional address details as required.
In the Delivery Requirements section, select how you would like to receive your results: U.S. Mail, Secure Fax, Encrypted Email, or Unencrypted Email. If choosing email options, provide the appropriate email address.
Complete the Information to be mailed to section by entering the company or person’s name and their contact details including phone number and address.
If you want an additional copy sent elsewhere, fill out the Additional Copy section with the same details as above.
Read through the authorization statements carefully. Your signature is required at the bottom along with the date and requestor's information if applicable.
Once completed, save your form and choose to either mail it, scan and email it, fax it, or drop it off at a Patient Service Center.

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Versions	Form popularity	Fillable & printable
2021	4.2 Satisfied (48 Votes)
2013	4.7 Satisfied (29 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 does authorization to disclose protected health information mean?

A HIPAA authorization is a detailed document in which specific uses and disclosures of protected health are explained in full. By signing the authorization, an individual is giving consent to have their health information used or disclosed for the reasons stated on the authorization.

What is an example of a HIPAA authorization?

I hereby authorize use or disclosure of protected health information about me as described below. 4. I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by federal privacy regulations.

What is an authorization for the disclosure of protected health information?

A HIPAA release form is a document that when signed allows healthcare providers to share a patients protected health information (PHI) with specified individuals or organizations, according to the details stipulated in the form.

How to fill out a disclosure authorization form?

How to create a HIPAA compliant medical records release form Provide instructions. Name the patient and individual authorized to use or disclose their PHI. Describe the information. Specify recipients. Specify the purpose of disclosure. Specify the time period. Detail their revocation rights. Obtain the patients signature.

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

0:43 1:58 A description of the protected. Health information to be used and disclosed. The person authorizedMoreA description of the protected. Health information to be used and disclosed. The person authorized to make the use or disclosure. The person to whom the covered entity may make the disclosure.

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How to fill out an authorization to disclose protected 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.

When using or disclosing protected health information or when requesting PHI from a covered entity?

A covered entity is permitted, but not required, to use and disclose protected health information, without an individuals authorization, for the following purposes or situations: (1) To the Individual (unless required for access or accounting of disclosures); (2) Treatment, Payment, and Health Care Operations; (3)