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Record Release Form

Authorization to Disclose Health Information

Patient Name:

Date of Birth:

I hereby authorize (previous provider): Dr. Heidi Mist M.D.

and/or their agents or representatives to review, make copies of and release my medical information to:

The information to be released or disclosed is as follows:

I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization, I must present my revocation in writing, I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. If I fail to specify an expiration date, event or condition in writing, this authorization will expire in six months.

I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that if the recipient of my information in Section 1, above is not a healthcare provider, a health plan, or health care clearing house, or not an entity required to comply with federal or state health privacy regulations, my heath information may be further disclosed by such recipient, and my information may no longer be protected by state and federal laws. If this authorization is for the disclosure of substance abuse information, the recipient may be prohibited from disclosing the substance abuse information under federal substance abuse confidentiality requirements.

I understand that may be required to pay a fee for this copying service as governed by the California Health and Safety Code #123110 and that my insurance company will not pay for this service.

Initial:

I acknowledge receipt of a signed copy of this authorization. Initial:

Patient or Personal Representative's Name: Date: Relationship to Patient:

Authorization to Release Restricted Information

I understand and hereby consent to the release of any and all alcohol and/or drug abuse information; information: relating to sexually transmitted diseases; Acquired immune Deficiency Syndrome (AIDS); Human Immunodeficiency Virus (HIV); or psychiatric treatment records under the same conditions outlined above. I understand that such information cannot be released without my specific consent.

Patient of Personal Representative's Name: Date:

Leave this empty:

Your legal name

Your email address

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Timestamp

Audit

April 7, 2022 5:20 pm PDT

Record Release Form Uploaded by Heidi Mist - info@drheidimist.com IP 130.41.57.11