Authorization to Disclose Health Information
for Your State
This Authorization to Disclose Health Information allows you to determine what type of medical information can be released and under what circumstances. This form is for use in all states and is available for instant download.
Your health and medical information is considered private and is afforded protection under federal and state laws. This Authorization to Disclose Health Information allows you the flexibility to determine what types of information can be released and under what circumstances. This form also complies with HIPAA (Health Insurance Portability and Accountability Act) Privacy Rules. This Authorization to Disclose Health Information can be revoked at any time.
These important provisions are included in this Authorization to Disclose Health Information:
Protect yourself and your rights by using our professionally prepared up-to-date forms.
This attorney prepared packet includes:
These important provisions are included in this Authorization to Disclose Health Information:
- Patient Information: Contains the patient’s name, date of birth, social security number and health record number;
- Authorization: Sets out the specific individual or organization authorized to make the disclosure;
- Type of Information to be Disclosed: Sets out the type and the date for the information being released;
- Purpose: Sets out the specific purpose for which the information is being disclosed;
- Signature: This provision sets forth a signature line for the patient or the patient’s legal representative.
Protect yourself and your rights by using our professionally prepared up-to-date forms.
This attorney prepared packet includes:
- Instructions and Checklist
- General Information
- Authorization to Disclose Health Information for use in all states
This is the content of the form and is provided for your convenience. It is not necessarily what the actual form looks like and does not include the information, instructions and other materials that come with the form you would purchase. An actual sample can also be viewed by clicking on the "Sample Form" near the top left of this page.
Number of Pages5
DimensionsDesigned for Letter Size (8.5" x 11")
EditableYes (.doc, .wpd and .rtf)
UsageUnlimited number of prints
Product number#21928
This is the content of the form and is provided for your convenience. It is not necessarily what the actual form looks like and does not include the information, instructions and other materials that come with the form you would purchase. An actual sample can also be viewed by clicking on the "Sample Form" near the top left of this page.