Medical Records Release Notes for HIPAA Compliance

Medical Records Release Form (HIPAA-Compliant) Section I I, John Doe, give my permission for City Health Hospital to share the information listed in Section II of this document with the person(s) or organization(s) I have specified in Section IV of this document. Section II – Health Information I would like to give the above healthcare organization permission to: full health record disclosure including diagnoses, lab test results, treatment, and billing. Form of Disclosure: Electronic copy or access via a web-based portal Section III – Reason for Disclosure At my request. Section IV – Who Can Receive My Health Information I give authorization for the health information detailed in section II of this document to be shared with the following individual(s) or organization(s) Name: Jane Smith Organization: Health Insurance Co. Address: 123 Insurance Lane, Suite 100, Metropolis, NY 10001 I understand that the person(s)/organization(s) listed above may not be covered by state/federal rules governing privacy and security of data and may be permitted to further share the information that is provided to them. Section V – Duration of Authorization This authorization to share my health information is valid: From 1 November 2025 to 1 November 2026 I understand that I am permitted to revoke this authorization to share my health data at any time and can do so by submitting a request in writing to: Name: Jane Smith Organization: Health Insurance Co. Address: 123 Insurance Lane, Suite 100, Metropolis, NY 10001 I understand that: - In the event that my information has already been shared by the time my authorization is revoked, it may be too late to cancel permission to share my health data. - I understand that I do not need to give any further permission for the information detailed in Section II to be shared with the person(s) or organization(s) listed in section IV. - I understand that the failure to sign/submit this authorization or the cancellation of this authorization will not prevent me from receiving any treatment or benefits I am entitled to receive, provided this information is not required to determine if I am eligible to receive those treatments or benefits or to pay for the services I receive. Section VI – Signature Signature: John Doe Date: 1 November 2024 Print your name: John Doe