Authorization for Release Of Medical Record Information


Please Note: Copy Fee May Be Charged For Medical Records


Above listed patient authorizes the following healthcare facility to make record disclosure:

2 years prior from last date seen

Dates Other

Specific Information Requested

Change of Insurance or Physician

Continuation of Care (e.g., VA Med Ctr)



RESTRICTIONS: Only medical records originated through this healthcare facility will be copied unless otherwise requested. This authorization is valid only for the release of medical information dated prior to and including the date on this authorization unless other dates are specified.

I understand the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse.


I understand I may revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the health information management department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.