Medical Records Request - Template, Sample Form Online Pro · US-law

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RE: Request for Copies of Protected Health Information — ________

Dear ________,

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I am requesting these records for the following purpose: ________.

I request that the records be provided to me in the following form or format, if readily producible: ________. Please deliver the records by the following method: ________.

I understand that, under 45 C.F.R. § 164.524, you are required to act on this request no later than thirty (30) days after receipt, and that any fee charged must be limited to a reasonable, cost-based fee as permitted by that regulation. If there is a charge associated with releasing these records, please submit an itemized billing statement together with the records, and payment will be remitted promptly upon receipt. The amount I have authorized in advance, if any, is $________.

I have enclosed a signed Authorization for Release of Medical Records. If you require any further information from me, you may contact me as follows:

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Thank you for your prompt attention to this matter.

Sincerely,

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Enclosure: Authorization for Release of Medical Records

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

(HIPAA-Compliant Authorization — 45 C.F.R. §§ 164.508 & 164.524)

§ 1. Patient Information.

Name: ________
Address: ________
Social Security Number: ________
Date of Birth: ________
Telephone: ________
Medical Record/Account No. (if known): ________

§ 2. Authorization for Release.

I, ________ (the "Patient"), hereby authorize the following health care provider (the "Disclosing Party") to release my protected health information:

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to release, disclose, and deliver the medical information described below to the following person or entity (the "Recipient"):

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§ 3. Description of Information to be Released.

I specifically authorize the release of only the following information for the date(s) of service indicated:

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Date(s) of service / treatment period covered: ________

I do not give permission for any other use or redisclosure of this information except as expressly authorized herein.

§ 4. Purpose of the Disclosure.

The information is being released for the following purpose: ________.

§ 5. Specially Protected Information.

Federal and state law afford special protection to certain categories of information. By initialing below, I specifically authorize the release of the following categories of specially protected information to the extent contained in my records (initial each that applies):

_____ Records relating to alcohol or substance use disorder treatment (42 C.F.R. Part 2);
_____ Records relating to mental or behavioral health treatment;
_____ Records relating to HIV/AIDS status or testing;
_____ Records relating to sexually transmitted infections;
_____ Records relating to genetic testing or information.

Patient Initials: ________

§ 6. Redisclosure.

This release does not authorize redisclosure of medical information beyond the limits of this consent. The Recipient is prohibited from using the information for any purpose other than the stated purpose, and from disclosing it to any other party without further written authorization. Where the information includes records protected by 42 C.F.R. Part 2, the following statement shall accompany the disclosure:

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I specifically understand and agree that the redisclosure requirements set out above will apply to these records. I further understand that once my information is disclosed to the Recipient, it may no longer be protected by federal or state privacy laws and may be subject to redisclosure by the Recipient.

§ 7. Right to Revoke.

I understand that I have the right to revoke this authorization at any time by submitting a written notice of revocation to the Disclosing Party named in § 2, except to the extent that action has already been taken in reliance upon it. Revocation will not apply to information that has already been released in response to this authorization.

§ 8. Expiration.

This authorization shall remain in effect until the purpose for which the information is to be used has been fulfilled, or until revoked in writing by the Patient. Unless otherwise revoked, this authorization will expire on the following date or event: ________.

§ 9. Acknowledgments.

I understand and acknowledge that: (a) I may refuse to sign this authorization; (b) treatment, payment, enrollment, or eligibility for benefits may not be conditioned on whether I sign this authorization, except as permitted under 45 C.F.R. § 164.508(b)(4); (c) I have the right to receive a copy of this signed authorization; and (d) I have read and understand the contents of this authorization and sign it voluntarily.

I authorize the release of information as indicated above.

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Signature of Patient

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Date

§ 10. Personal Representative (if applicable).

If this authorization is signed by a personal representative of the Patient, complete the following:

Name of Personal Representative: ________
Relationship / Authority to Act: ________

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Signature of Personal Representative

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Date