Maryland HIPAA Release Form

Maryland HIPAA Release Form **AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION** I, John Doe, authorise the release of my protected health information as described below. **Patient Information:** * **Patient Name:** John Doe * **Date of Birth:** 15/03/1985 * **Address:** 123 Oak Street, Anytown, MD 21001 * **Phone Number:** (555) 123-4567 * **Email:** john.doe@email.com **Information to be Released:** * **Type of Information:** All medical records including, but not limited to, progress notes, laboratory results, imaging reports, and discharge summaries. * **Dates of Service:** 01/01/2020 to 01/11/2024 * **Purpose of Release:** To facilitate coordinated care with a new specialist and for insurance claim processing. **Recipient of Information:** * **Name of Recipient:** Dr. Sarah Miller, Cardiology Associates * **Address:** 456 Pine Avenue, Medicity, MD 21002 * **Phone Number:** (555) 987-6543 * **Fax Number:** (555) 987-6544 **Expiration:** * **This authorisation will expire on:** 01/11/2025 (One year from date of signing) * **Or upon the occurrence of the following event:** Completion of insurance claim processing. **Patient Rights:** I understand that I have the right to revoke this authorisation at any time by providing written notice to the releasing entity. I understand that a revocation will not affect any information already released in reliance on this authorisation. I understand that the information disclosed pursuant to this authorisation may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations. I understand that I may refuse to sign this authorisation and that my refusal will not affect my treatment, payment, enrollment in a health plan, or eligibility for benefits. **Signature:** * **Patient or Legal Representative Signature:** John Doe * **Printed Name of Patient or Legal Representative:** John Doe * **Relationship to Patient (if applicable):** Self * **Date:** 01 November 2024 **Witness (if required):** * **Witness Signature:** Jane Smith * **Printed Name of Witness:** Jane Smith * **Date:** 01 November 2024 **For Office Use Only:** * **Date Received:** 01 November 2024 * **Staff Initial:** JS Clinician Specialty: Medical Record Administrator