Free Sample Authorization to Disclose Health Information Form

Authorizations to Disclose Health Information are used when you desire to allow others to disclose information regarding your health. This authorization spells out the specific information to be disclosed, who is authorized to do so and the purposes for disclosure. You may revoke the authorization at any time.

Disclaimer:This was not drafted by an attorney & should not be used as a legal document.

Authorization to Disclose Health Information

_________________ (“Patient”) of __________________________________(Address), with Social Security Number ___________________, hereby authorizes the release, disclose, and delivery of the medical information described below to: ______________.

Specific Authorization.  I specifically authorize the disclosure of all medical information relating to the above-named patient.

I do not give permission for any other use or re-disclosure of this information.

This Authorization to Disclose Health Information shall expire on _____________ from the date of my signature.

I reserve the right to revoke this authorization by sending a written notice to the person or entity authorized to make the disclosure described above.

I agree that any release which has been made prior to revocation and which was made in reliance upon this authorization shall not constitute a breach of my rights to confidentiality.

I authorize the disclosure of information as indicated above.

____________________                                            ________________

Patient                                                                         Date

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