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I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form. HIPAA Privacy Authorization Form.In these cases, you'll need to have your patient sign a HIPAA medical records release form. The form gives healthcare professionals permission to share a patient's medical information with certain other parties. DISCLOSURE: Voluntary. Failure to sign the authorization form will result in the non-release of the protected health information. All portions of this form must be completed to constitute a valid authorization for release of health information under the. Or RELEASE MEDICAL. INFORMATION. The written authorization form is commonly called a HIPAA medical release form (or medical records release authorization form). The Health Information Portability and Accountability Act (HIPAA) has rules in place to protect health information from being improperly used or disclosed.
