Medical Records Release Notes for HIPAA Compliance

Please complete all sections of this HIPAA release form. If any sections are left blank, this form will be invalid, and it will not be possible for your health information to be shared as requested. Section I I, [insert full legal name of the individual authorising release] (insert full name of the person giving permission exactly as stated in official records; only include if explicitly provided), give my permission for [insert name of the healthcare organization authorized to release the information] (insert full name of the organisation responsible for disclosing the health information; only include if explicitly mentioned) to share the information listed in Section II of this document with the person(s) or organization(s) I have specified in Section IV of this document. Section II – Health Information I would like to give the above healthcare organization permission to: [insert statement describing which records should be disclosed] (only include one of the following options as applicable: full health record disclosure including diagnoses, lab test results, treatment, and billing; OR full health record excluding specific categories — mental health records, communicable diseases including HIV/AIDS, alcohol/drug abuse treatment records, genetic information, or other; must match user's explicit selections. Presented in line format.) Form of Disclosure: [insert format of disclosure, such as 'Electronic copy or access via a web-based portal' or 'Hard copy'] (include only if specified. Match formatting exactly as in original — i.e., on the same line, not listed unless shown that way in the original.) Section III – Reason for Disclosure Please detail the reasons why information is being shared. If you are initiating the request for sharing information and do not wish to list the reasons for sharing, write ‘at my request’. [insert reason for disclosure] (write a short paragraph in full sentences detailing all relevant reasons for requesting the release of information, as described by the individual. If the patient simply writes "at my request", include that exact phrase. Do not paraphrase or summarise.) Section IV – Who Can Receive My Health Information I give authorization for the health information detailed in section II of this document to be shared with the following individual(s) or organization(s) Name: [insert full name of recipient individual] (enter only if explicitly provided) Organization: [insert name of recipient organization] (enter only if explicitly provided) Address: [insert full mailing address of recipient] (enter complete address exactly as stated; only include if mentioned) I understand that the person(s)/organization(s) listed above may not be covered by state/federal rules governing privacy and security of data and may be permitted to further share the information that is provided to them. Section V – Duration of Authorization This authorization to share my health information is valid: [insert selected timeframe option from the following] a) "From" [insert start date] "to" [insert end date] Or b) "All past, present, and future periods" Or c) "The date of the signature in section VI until the following event:" [insert description of triggering event] (Select only the option that was explicitly chosen by the individual completing the form. Keep formatting inline and identical to the original.) I understand that I am permitted to revoke this authorization to share my health data at any time and can do so by submitting a request in writing to: Name: [insert recipient name for revocation notice] (include only if mentioned) Organization: [insert organization name for revocation notice] (include only if mentioned) Address: [insert mailing address for revocation notice] (include only if mentioned) I understand that: - In the event that my information has already been shared by the time my authorization is revoked, it may be too late to cancel permission to share my health data. - I understand that I do not need to give any further permission for the information detailed in Section II to be shared with the person(s) or organization(s) listed in section IV. - I understand that the failure to sign/submit this authorization or the cancellation of this authorization will not prevent me from receiving any treatment or benefits I am entitled to receive, provided this information is not required to determine if I am eligible to receive those treatments or benefits or to pay for the services I receive. Section VI – Signature Signature: [insert handwritten or digital signature of the individual] (include only if explicitly provided) Date: [insert date of signature] (include only if explicitly provided) Print your name: [insert full printed name of individual signing the form] (include only if explicitly provided) If this form is being completed by a person with legal authority to act an individual’s behalf, such as a parent or legal guardian of a minor or health care agent, please complete the following information: Name of person completing this form: [insert full name of legal representative] (only include if applicable and explicitly stated) Signature of person completing this form: [insert representative's signature] (include only if provided) Describe below how this person has legal authority to sign this form: [insert explanation of legal authority] (write a short paragraph or list format — matching the example — describing the legal basis for the person’s authority to complete and sign the form on behalf of the individual.) (Never come up with your own patient details, authorisation terms, recipients, legal reasoning, or any personal data — use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Maintain all formatting and paragraph structure exactly as per the source document.)