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Authorization for Release of Medical Information


Overview
The Authorization for Release of Medical Information is used by an individual to consent to the release of his or her medical records.  
It may also be used by a parent or legal guardian to consent to the release of a child's records or by someone acting as an attorney in fact through a power of attorney.
Doctors, hospitals, employers and others often have their own authorization forms, so check first to see whether one will be supplied to you.  
If you are seeking records pertaining to mental health or HIV/AIDS, consult with your provider to determine if any special documentation is required.
This document should not be used if the proposed disclosure is for records to be used in a lawsuit, nor should it be used if the information is to be released to a third party payer.  In these cases, talk to your attorney before giving any authority to release your records.

When You Need It
-Used when a patient wants to initiate the release of records to a new or different doctor.  
-Used to consent to disclosure of medical records in connection with a job application or when applying for certain insurance.  
-Used to request medical records be transferred to a new provider.

Getting Started

You will need:
-The name and address of the health care provider releasing the records.
-The name, address, social security number, and date of birth of the person whose records are being released.
-The name and address of the health care to whom the records are being sent. 
-Any details regarding what information is to be released and the length of time the authorization will remain in force.

When to Review and Revise  
-When moving or changing health care providers.