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Authorization for Release of Medical Records
HIPAA-compliant authorization form allowing a covered entity to release a patient's protected health information to a designated third party.
PDF TemplateUse the instructions below to complete this form
Instructions
Include all elements required by 45 CFR 164.508: specific description of the information to be disclosed, identification of the person or entity authorized to make and receive the disclosure, purpose of the disclosure, expiration date, and the patient's right to revoke. The authorization must be written in plain language. Psychotherapy notes and substance abuse records may require separate authorizations.