R0056_authorizationandrequest_forrecords.indd

Authorization for Release of Records
and Request for Records
Health Services • Curry Hall, Room 131 • 505-562-2321 This form is to confirm your authorization to use or disclose your protected health information
for a special purpose.
Individual Patient (or personal representative) confirming the authorization
I give my authorization to use or disclose my protected health information as described in Section 2 below. I give
this authorization voluntarily.
Individual patient’s name:
Your address:
Your date of birth:
Your phone number:
Your Social Security Number:
The use and/or disclosure authorized
The following records will be released to the entity listed below. Mark all that is applicable.
 All patient records
Receive records
Name the people and/or organizations (or physician/hospital) that you are authorizing to receive and use your protected
health information.
Release records
Name the people and/or organizations (or physician/hospital) that you are authorizing to release and use your protected
health information.
Contact Information
Page 1 of 2
Individual Patient’s Authorization
Describe each purpose for which you are authorizing your protected health information to be used and/or disclosed.
Please check:
 Moving
 O.B. patient who is traveling and needs records  Other (Please specify.) Ending this authorization
This authorization will end on the following date: If expiration date is not noted, this authorization expires one year from date below.
Changing your mind about this authorization
I understand that I may revoke this authorization at any time by giving written notice to the Privacy Officers at your
office. However, I understand that I may not revoke this authorization for any actions before receipt of my written notice to
revoke this authorization. In addition, I understand that if I am giving this authorization as a condition of obtaining
insurance coverage, and I revoke this authorization, the insurance company has a right to contest my claims under the
insurance policy.
Signing this authorization is not a condition of treatment
I understand that under most circumstances a healthcare provider may not condition treatment, payment, enrollment, or
eligibility for benefits on my signing this authorization. However, I understand that signing an authorization that permits
the use and/or disclosure of my protected health information for research purposes may be a condition of my treatment if
I am undergoing research-related treatment. Also, I may be required to sign an authorization if my treatment is provided
solely for the purpose of creating protected health information for disclosure to a third party. And under some
circumstances, a health plan may condition my enrollment in a health plan or my eligibility for benefits on my
providing an authorization permitting the health plan to make enrollment and eligibility determinations. The authorization
may include release of sexually diseases, Acquired Immunodeficiency Syndrome (AIDS) or Human Immunodeficiency
Virus (HIV), developmental disabilities or behavioral and mental health services or conditions, and treatment for alcohol
or drug use.
Individual patient’s signatures
I have had the chance to read and think about the content of this authorization form and I agree with all statements made
in this authorization. I understand that, by signing this form, I am confirming my authorization for use and/or disclosure of
the protected health information described in this form with the people and/or organizations named in this form.
Signature:
If this authorization is signed by a personal representative for the individual patient: Personal representative’s name (Print name.):
Signature:
You have the right to have a copy of this form after you sign it.
Submit the authorization to the Privacy Official and include a copy in the individual patient’s medical record.
Page 2 of 2

Source: https://enmu.edu/services/health/forms/r0056_authorizationandrequest_forrecords_typable.pdf