MOH Health Information Release Authorization Form

Health Information Release Authorization Form

Please complete this form to authorize the release of your health information.
Patient Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Patient Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient Email Address
example@example.com
Patient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Health Information Released From:

Please provide the Health Information is being released from below.
Recipient Name or Organization
Name or Third-Party Org/Clinic
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Recipient Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Health Information Released To:

Please Provide the Health Information to be released below.
Specific Date/Year of the Treatment

MonthDayYear
Date
Type of Health Information to be Released
Information to be Released (describe specifically)
Purpose of Release
Delivery Method
Please list Other Location (if applicable)
Purpose For Release
Other (if applicable)
Authorization Expiration Date (if applicable)

MonthDayYear
Date
Authorization

Please read carefully and sign below to continue
I understand that by signing this form, I am requesting that the health information specific be sent to the third party listed above. I understand that I may revoke this request at any time in writing to summit orthopedics. The revocation will not apply to records already released. Summit Orthopedics will not condition treatment on whether I sign this authorization. I understand that the information can be re-disclosed by the third-party list above and once received it may no longer be protected by federal or state privacy laws. I understand that records released may include information received from other third parties. I am aware that some requests may incur a fee as allowed by law. This Authorization will end once a year from the date the form is signed. If you want to end on a sooner date, enter the date below.
This Authorization will end once a year from the date the form is signed. If you want to end on a sooner date, enter the date below.

MonthDayYear
Date
Print Name of Patient or Representative

First NameLast Name
Signature

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Date Signed

MonthDayYear
Date
Relationship/Authority

If you are not the patient, list your relationship/authority to sign on patients behalf (examples: parent, legal representative, power of attorney for healthcare, etc.). Representatives signing this form on behalf of a patient may be requested to submit documentation of the relationship/authority.
Name

First NameLast Name
Relationship
Signature

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Should be Empty:

Health Information Release Authorization Form

Health Information Released From:

Health Information Released To:

Authorization

Relationship/Authority