Note: This is a reference translation to help you understand a typical form. It is not an official document. Your provider's actual form may differ — always sign the provider's own version.
When you receive this formWhen you want to share your health records with another provider, a specialist, a family member, an attorney, or any other third party. Also presented when an insurer or employer requests your records and requires your written permission.
What to bring or have readyYour photo ID and the full name and mailing address (or fax number) of the person or organization that will receive your records. Knowing the exact date range of records you want to share will help you complete the form accurately.
Patient Identification
English
What this field means
Patient Legal Name
Your full legal name as it appears on your government-issued ID and in your medical records. This links the authorization to the correct patient file.
Date of Birth
Your date of birth used alongside your name to confirm you are the correct patient. Required by most providers to process this type of request.
Address
Your current mailing address. Some providers use this as a secondary identifier to confirm the correct patient record, and to mail copies of records to you if requested.
Information to Be Disclosed
English
What this field means
Description of Health Information to Be Disclosed
A specific description of what health information may be disclosed. Under HIPAA, a valid authorization must contain a description of the information to be used or disclosed that identifies the information in a specific and meaningful manner. You may specify a condition, procedure, or event rather than all records.
Type or Category of Records
The type of records to be released — for example, lab results, imaging, visit notes, discharge summaries, or a complete medical record. Being specific limits unintended disclosure of sensitive information.
Date Range of Records
The start and end dates of the records you are authorizing for disclosure — for example, from January 1, 2022 to the date you sign this form. Limiting the date range protects older records that may not be relevant.
Purpose and Recipient
English
What this field means
Person or Entity Authorized to Disclose
The name of the healthcare provider, hospital, clinic, or other entity that currently holds your records and is being authorized to release them. Under HIPAA, this must identify the person(s) or class of persons authorized to make the disclosure.
Person or Organization Authorized to Receive
The name and address (or fax number) of the individual or organization that will receive your records. Under HIPAA, this must identify the person(s) or class of persons to whom the covered entity may make the disclosure. Be as specific as possible.
Purpose of the Disclosure
The reason the information is being shared — for example, 'continuity of care with a new specialist', 'insurance claim processing', 'legal proceedings', or 'personal use'. Under HIPAA, a valid authorization must describe each purpose of the requested use or disclosure.
Expiration
English
What this field means
Expiration Date
The specific date on which this authorization stops being valid. Under HIPAA, a valid authorization must include an expiration date or expiration event. Choose a date that gives enough time to complete the records transfer without leaving it open indefinitely.
Expiration Event (If No Specific Date)
If a specific expiration date is not appropriate, you may describe an event that ends the authorization — for example, 'upon completion of treatment' or 'one year from the date of signing'. Either an expiration date or an expiration event is required.
Patient Signature
English
What this field means
Signature of Individual or Authorized Representative
Your handwritten or electronic signature confirming you voluntarily authorize this disclosure. Under HIPAA, a valid authorization must be signed by the individual or their authorized representative. You have the right to revoke this authorization at any time in writing.
Date Signed
The date you are signing this form. The authorization is generally not valid if signed before its effective date. Write today's date.
Authority to Sign (If Signing on Behalf of Patient)
If you are not the patient — for example, you are a parent signing for a minor child, or a legal guardian or healthcare proxy — state your name, your relationship to the patient, and the legal basis for your authority to sign. Leave blank if you are the patient.