Name: _________________________________ Address:_______________________
Date of Birth: _____________________________ ______________________________
Social Security Number_____________________(optional) ______________________________
Release from Health Insurance Portability & Accountability Act
I understand my rights under the Health Insurance Portability & Accountability Act and specifically authorize the release of
my confidential documents. I request a complete copy of my medical records be sent to:
Name:___________________________________________________________
Address:_________________________________________________________
City, State, ZIP:____________________________________________________
or to be copied and given to me on my next appointment on ____________________________
According to HIPAA / Patients Bill of Rights, I am entitled to a copy of records and will not incur any additional payment.
Signed:_________________________________
Date: __________________________________
You may want to add reference to options to the effect "I request a complete copy of my medical records pertaining to my
treatment by you from January 1, 2007 through February 15, 2008." or "I request a complete copy of my medical records
pertaining to your treatment of me for my thyroid condition" or "pertaining to your treatment of me resulting from my
accident on September 14, 2007."
