Patient Authorization To Release Medical Records to Self
When my information is used or disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule.
I understand I may refuse to sign this authorization. If I refuse, the identified records will not be disclosed. Whether I sign or refuse to sign, my treatment will not be affected.
I understand also that I may revoke this authorization, in writing at any time except to the extent that action has been taken in reliance thereon. This consent will remain in effect no more than ninety (90) days from the date I signed this Authorization to accomplish its purpose.
I understand that my medical records may contain alcohol/drug abuse, mental health information, HIV results and /or STI testing results. I give special authorization to the health care provider/facility to release this information in my records to the person, physician, facility named above for the stated purpose.
I am aware of the charges for my medical records determined by the Secretary of Health:
Pages 1 thru 20 - $1.83
Pages 21 thru 60 - $1.36
Pages 61+ - $0.47