I hereby authorize the use and disclosure of my health information as described below. I understand that this authorization is voluntary. I understand that if the recipient of this information is not a health plan or healthcare provider, the information disclosed may no longer be protected under federal privacy regulations.

To help protect your privacy and prevent unauthorized release of medical information, please upload a clear photo of a valid government-issued photo ID (such as a driver’s license, state ID, passport, military ID, or other government-issued identification). If you are requesting records on behalf of another individual, please also upload documentation showing your legal authority to make this request.

Please upload or take a clear photo of one of the following government-issued photo IDs:

• Driver’s license
• State-issued identification card
• U.S. passport or passport card
• Military ID
• Permanent resident card (Green Card)
• Tribal identification card
• Foreign passport
• Other government-issued photo identification

 

For parents/legal guardians requesting records for a minor, please upload both:

• Parent/guardian photo ID
• Documentation establishing authority if needed (examples: birth certificate, guardianship paperwork, court order)

 

If the request is for an adult represented by another person, please upload both:

• Representative’s photo ID
• Supporting documentation (power of attorney, guardianship paperwork, executor documentation, etc.)

 

Incomplete or incorrect identifying information or supporting documentation may delay the processing of this Authorization for Disclosure of Health Information.

Unless checked or listed below, I understand that the following information may be released (as defined by applicable state and federal laws).

I understand that I have the right to inspect and receive a copy of the information to be disclosed. I understand that I may revoke this authorization at any time by providing written notice, except to the extent that action has already been taken based on this authorization prior to receipt of the revocation. My decision to sign this authorization will not affect my treatment. I understand that if my information is disclosed to an individual or organization that is not a healthcare provider or health plan, the information may no longer be protected by federal privacy regulations and could be shared again by the recipient (re-disclosed). I understand that a photocopy, facsimile, or scanned copy of this authorization shall be considered as valid as the original.