Authorization to Release Health Information 1
Practice:
Patient:
Name:
S.S.N.:
Birth Date:
(Print/type name and address of health
care provider)
Release to:
Chris L. Ingold, or his staff
Ingold Law, LLC
1525 Josephine Street, Denver, CO 80206
chrisingold@mac.com
FAX (303) 328-3531
(Requestor)
As the custodian/parent of the above-noted child, I authorize the above-named doctor or health care provider to release to the
above-noted requester my child’s health information (as specified below) maintained by the above-named doctor or health care
provider. I understand that the information to be released includes or may include information regarding the following conditions:
Drug abuse, if any Alcoholism or alcohol abuse, if any Psychological or psychiatric conditions, if any (including
psychotherapy notes and raw data concerning psychological/psychiatric testing) Sickle Cell Anemia, if any HIV/AIDS, if any
This authorization also does authorize any oral communications with any physician or other health
care provider, or with their assistants, employees, clerical staff, or other agents.
Information Requested:
√
Copy of history and physical,
discharge summary and operative reports
√
Copy of outpatient and E.R. admissions
√
Copy of complete hospital chart
√
Pharmacy and/or prescription records
√
Entire chart, including office notes and letters
√
Other (specify): any records of injuries, treatment or
evaluations, including records from other providers.
Dates Covered:
√
All admission or care at this
facility or by this doctor
_____ Limited to treatment dates
for conditions described below:
_______________________________
_______________________________
_______________________________
The purpose or need for which information is to be used is “at the request of” the undersigned, see 45 CFR 164.508(c)(1)(iv):
√ Other
CFI services pursuant to Court Order
Authorization - I certify that this request has been made voluntarily and that the information given above is accurate to the best of my
knowledge. I understand that I may revoke this authorization at any time, e.g., pursuant to 45 CFR 164.508(b)(5), except to the extent
that action has already been taken to comply with it. Without my express revocation, this consent will automatically expire upon
satisfaction of the need for disclosure, but in any event:  four years from the date noted below by signature (date supplied by
patient); or  if revoked in writing by me or my representative; or  under the following condition(s):
(1)
; or if
___________________________________________________________________________________________________
(2)
___________________________________________________________________________________________________
Other conditions - A copy of this signed authorization:  may,  may not be utilized with the same effectiveness as an
original.
I understand that, pursuant to 45 CFR 164.508(b)(4), I do not have to sign this authorization in order to get health care benefits
(treatment, payment or enrollment). Although I prohibit redisclosure of my medical records by those receiving the above authorized
information (without my further written consent), I also understand the potential for information disclosed pursuant to this
authorization to be subject to redisclosure by the recipient and no longer be protected by 45 CFR 164, Subpart E.
1
This authorization has been drafted to contain the elements and otherwise meet the requirements specified at 45 CFR 164.508.
PERSON AUTHORIZED TO SIGN FOR PATIENT,
IF ANY
_____________
DATE
______________________________
SIGNATURE OF PATIENT
_________________________________
Print or type name
State how authorized:_________________________