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AUTHORIZATION TO DISCLOSE HEALTH INFORMATION MEDICAL RECORDS RELEASE alexandriaradiology.com ALEXANDRIA IMAGING CENTER 4660 Kenmore Avenue, Suite 525 Alexandria, VA 22304 P 703.751.5055 F 703.370.3889

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What is authorization to disclose health?

Authorization to disclose health is a legal document that allows a healthcare provider to share an individual's medical information with designated individuals or organizations.

Who is required to file authorization to disclose health?

The individual whose health information is being disclosed is required to file the authorization to disclose health.

How to fill out authorization to disclose health?

Authorization to disclose health can be filled out by providing the individual's personal information, specifying who can access the medical records, and signing and dating the form.

What is the purpose of authorization to disclose health?

The purpose of authorization to disclose health is to protect the privacy of an individual's medical information and ensure that it is only shared with authorized individuals or organizations.

What information must be reported on authorization to disclose health?

The authorization to disclose health form must include the individual's name, date of birth, types of information being disclosed, recipients of the information, expiration date, and signature.

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