Medical Record Release Authorization

Let patients authorize sharing their health information with another provider, organization or person. It names who releases and who receives the records, what is shared and the terms the patient accepts.

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In the Claude connectors directory

Section

Patient Name

First Name

Last Name

Date of Birth

Phone Number

Address

Street Address

City

State / Province

ZIP / Postal Code

Section

Releasing Provider or Physician Name

First Name

Last Name

Organization Name

Releasing Provider Phone Number

Fax Number

Releasing Provider Address

Street Address

City

State / Province

ZIP / Postal Code

Section

Recipient Name

First Name

Last Name

Recipient Organization

Recipient Address

Street Address

City

State / Province

ZIP / Postal Code

Recipient Phone Number

Recipient Fax

Section

Information I authorize for release

Complete medical record Lab results Imaging reports Medication list Discharge summary Mental health records Billing records

I understand and agree that

I may revoke this authorization in writing at any time My treatment does not depend on signing this form Disclosed information may be shared again by the recipient This authorization expires one year after signing

Date

Signature

Sign here