Authorization for Release of Health Information

Use this form to request the release of your health information either to or from a third party.

Graduation Date Graduation Date / MM / DD YYYY
Name Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Last 4 Digits of your SSN
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Email
Health Information to be Released
I authorize the release of the following health information:

I authorize the release of the following health information: Entire Medical History History/PE Exam Progress Notes Substance Abuse (including alcohol/drug) Lab Results Mental Health Xray Reports Immunizations Other Other
This authorization is:

This authorization is: at my request. at another's request (Please specify the Doctor or Institution):
Address to Send Health Information Address to Send Health Information
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Fax number to Send Health Information Fax number to Send Health Information - ### - ### ####
Conditions of Release

1. This authorization will expire on the date or event indicated below.

2. I may revoke this authorization at any time by notifying Bard Health Service and it will be effective on the date notified except to the extent that Bard Health Service has acted upon such Authorization

3. Information used or disclosed pursuant to this Authorization may be subject to redisclosure by the recipient and no longer protected by Federal privacy regulations.

4. By authorizing this release of information, my healthcare and payment for my health care will not be affected if I do no sign this Authorization form.
1. This authorization will expire (please enter a date or an event)
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

Authorization for Release of Health Information

Authorization for Release of Health Information

Health Information to be Released

Conditions of Release