When you receive this form当您希望与其他提供者、专科医生、家庭成员、律师或任何其他第三方共享健康记录时。当保险公司或雇主请求您的记录并需要您的书面许可时也会出现。
What to bring or have ready您的带照片身份证件，以及将接收您记录的人员或组织的全名和邮寄地址（或传真号码）。了解您希望共享的记录的确切日期范围将帮助您准确填写表格。
患者身份信息 / Patient Identification
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Patient Legal Name
患者法定姓名
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.
您的法定全名，与政府颁发的身份证件和医疗记录中的姓名一致。这将授权与正确的患者文件关联。
Date of Birth
出生日期
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.
您的出生日期，与姓名一起用于确认您是正确的患者。大多数提供者在处理此类请求时要求提供。
Address
地址
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.
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.
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.
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.
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.
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.
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.
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.
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.
Signature of Individual or Authorized Representative
本人或授权代表的签名
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.
The date you are signing this form. The authorization is generally not valid if signed before its effective date. Write today's date.
您签署此表格的日期。如果在生效日期之前签署，授权通常无效。请写今天的日期。
Authority to Sign (If Signing on Behalf of Patient)
签署授权（如代患者签署）
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.