Records Request

Records Request Authorization Form

I herby authorize you to use or disclose the specific information described below, only for the purposes and parties also described below.

Description of the specific information to be used or disclosed:

_____________________________________________________________________________________________________________

______________________________________________________________________________________________________________

Person or entity requesting the information and authorized to make the requested use or disclosure:

_____________________________________________________________________________________________________________

Recipient of this information: ______________________________________________________________________________________

______________________________________________________________________________________________________________

This information is being requested for the following purpose(s):

______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

This authorization shall remain in effect form the date signed below.

I understand that:

	I may inspect or copy the protected health information to be used or disclosed
	I may revoke this authorization in writing by contacting your office, attention Privacy Officer
	Information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient and no longer be protected by HIPPA
	I may refuse to sign this authorization and that you will not condition treatment or payment on me providing this authorization (expect to the extent that the authorization is for research-related treatment, in which case you may refuse to provide that research-related treatment

Patient Name: ______________________________________________ Signature: __________________________________

Date: ____________________________

Relationship to Patient

(if signed by personal respresntative of Patient): _________________________________ Date:__________________