PHI Authorization to Release Form

Collects authorization details for the release of protected health information, including recipient, purpose, duration, and revocation terms.

Patient Information

• Patient Full Name
• Date of Birth
  Optional unless needed to distinguish records. Do not collect if not necessary.
• Medical Record Number
  Optional internal identifier if your organization uses one.
• Phone Number

Recipient and Disclosure Details

• Recipient Name
• Recipient Organization
• Relationship to Patient
• Information to Be Released
• Describe Other Information

Purpose and Duration

• Purpose of Disclosure
• Authorization Start Date
• Authorization End Date
  Leave blank if the authorization expires on a specific event instead of a date.
• Expiration Event
  Use this only if the authorization expires based on an event, such as completion of treatment or a specific claim decision.

Revocation and Consent

• I understand that I may revoke this authorization in writing at any time, except to the extent action has already been taken in reliance on it.
• I understand that information disclosed under this authorization may no longer be protected by HIPAA if received by a non-covered entity.
• I authorize the release of the PHI described above to the recipient listed on this form.
• Patient Signature
• Signature Date