Health Information Release Authorization Form

A health information release authorization form is a sensitive form. This is because it shares delicate information about the patient. With this form, a patient can themselves consent to release health information about them.

This type of form may be found in clinics, hospitals, facilities, insurance companies whereby the insurance company needs to know the medical history of the concerned individual before they do business with them, etc.

It is an important form that the patient needs to carefully think about before signing as it will permit a doctor or hospital, facility, etc. to release their medical history.

Tips on composing the form

  1. Start off by indicating the patient’s name and date of birth, add any other details of the patient required.
  2. The patient needs to indicate when the authorization will expire clearly. It can be when information is received, in one year, on a date, etc.
  3. The patient’s doctor needs to be stated. Their name, address, email, phone, fax, whether it was a provider or facility where the patient went.
  4. It should be stated who the person authorizes to request, send, discuss their health information with. This can be a person, facility or even provider.
  5. The place the information is going to and who is sending it needs to be stated, i.e., address, phone, fax, the name of the person, provider or even facility, etc.
  6. Indicate the scope of the information that is authorized to be released.
  7. An area concerning authorization needs to be present. Over here the patient will sign, and there can be a signature of a witness. In cases where the patient is not able to sign, the relationship of the authorizing individual to patient needs to be stated.
  8. An area stating what information cannot be released needs to be present, this can include the patient’s HIV status.
  9. The patient’s rights need to be stated clearly so that the patient knows what they are getting into and later on not accuse anyone of wrongly releasing their health information.

It can be gathered that the health information release authorization form is indeed a very important form that needs to be carefully composed so that no one can, later, accuse anyone of wrongdoing.


Health information release authorization form

Format: MS Word [.docx] | Download

Simi Karton

Dr. Simi Karton currently resides in Los Angeles with her husband. This website is a voluntary work of Dr. Karton to provide people with useful health-related information with a straightforward approach.

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