Medical record Release Authorization Form
The medical record information release (HIPAA), also known as the
‘Health Insurance Portability and Accountability Act’, is included in each person’s medical file.
This document allows a patient to list the names of family members, friends, clergy, health care providers,
or other third (3rd) parties to whom they wish to have made their medical information available.
If anyone would ask for medical information regarding a specific patient and their name is not
listed on the HIPAA form, they would not be privy, by law, to any of the patient’s information
under any circumstances. The document also provides the ability for healthcare providers to share
information with each other.
This document may be revoked and/or reassigned at the discretion of the patient at any time.