[{"@context":"https:\/\/schema.org\/","@type":"BlogPosting","@id":"https:\/\/www.kregerbrodish.com\/blog\/free-form-friday-hipaa-medical-authorization-form\/#BlogPosting","mainEntityOfPage":"https:\/\/www.kregerbrodish.com\/blog\/free-form-friday-hipaa-medical-authorization-form\/","headline":"Free Form Friday: HIPAA Medical Authorization Form","name":"Free Form Friday: HIPAA Medical Authorization Form","description":"Today\u2019s free form is a HIPAA Medical Authorization that our Personal Injury Attorneys have clients sign in order to obtain our clients\u2019 medical records. We have drafted this form to have all of the information that the most common North...","datePublished":"2013-03-15","dateModified":"2026-04-15","author":{"@type":"Person","@id":"https:\/\/www.kregerbrodish.com\/blog\/author\/tom\/#Person","name":"Tom Kreger","url":"https:\/\/www.kregerbrodish.com\/blog\/author\/tom\/","identifier":37,"image":{"@type":"ImageObject","@id":"https:\/\/secure.gravatar.com\/avatar\/989ba622d7f3c2ae5baa2975686fdc6764e9eecb9e659bfdafb16f9a6b9000f6?s=96&d=mm&r=g","url":"https:\/\/secure.gravatar.com\/avatar\/989ba622d7f3c2ae5baa2975686fdc6764e9eecb9e659bfdafb16f9a6b9000f6?s=96&d=mm&r=g","height":96,"width":96}},"publisher":{"@type":"Organization","name":"Kreger Brodish LLP","logo":{"@type":"ImageObject","@id":"https:\/\/www.kregerbrodish.com\/wp-content\/uploads\/2021\/10\/Kreger-Brodish-LLP-Logo.png","url":"https:\/\/www.kregerbrodish.com\/wp-content\/uploads\/2021\/10\/Kreger-Brodish-LLP-Logo.png","width":417,"height":225}},"image":{"@type":"ImageObject","@id":"https:\/\/www.kregerbrodish.com\/wp-content\/uploads\/2021\/10\/Free-Samples-scaled.jpeg","url":"https:\/\/www.kregerbrodish.com\/wp-content\/uploads\/2021\/10\/Free-Samples-scaled.jpeg","height":1707,"width":2560},"url":"https:\/\/www.kregerbrodish.com\/blog\/free-form-friday-hipaa-medical-authorization-form\/","about":["Blog"],"wordCount":437,"keywords":["hipaa medical authorization form"],"articleBody":"Today\u2019s free form is a HIPAA Medical Authorization that our Personal Injury Attorneys have clients sign in order to obtain our clients\u2019 medical records. We have drafted this form to have all of the information that the most common North Carolina hospitals require.\u00a0If you are looking to obtain someone\u2019s medical records for a legal case (or other use), have that person sign a form like the one below and you should be able to order that person\u2019s medical records without too much trouble.Authorization for Release of Medical InformationPatient Name: ____________________________________________________Patient Address: ___________________________________________________Patient Date of Birth: ________________________________________________Patient Social Security #: ______________________________________________Patient Phone Number: _______________________________________________Date(s) of Treatment: ________________________________________________Medical Facilities Authorized to Release Information:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Authorized recipient of Information: _______________________________________Expiration of this authorization: __________________________________________Information to be released and disclosed:All information of any kind on file concerning me including, but not limited to, Medical Bills, Patient Billing Records, Pictures\/Photos, Clinic Notes, Summary Health Information (all dictated reports), History and Physical, Discharge Summary, Operative Report, Entire Record, Laboratory Reports, Radiology Reports, Emergency Department Reports, Physical Therapy\/Occupational Therapy Notes, Patient Discharge Instructions, X-ray Films, Electronic Medical Records, Consultations, Emergency Room Record, EDG\/ECG Tests, Therapy Notes, Progress Notes, Medication Records, Doctor\u2019s Orders, Nurse\u2019s Notes, Treatment Plans, Commitment Papers, Pathology Reports, MAR, Urgent Care Center Notes, etc.Purpose or Need for release or disclosure: _____________________________.I understand I may refuse to sign this authorization, and that my refusal to sign this form will not adversely affect my ability to receive health care services, reimbursement for services, enrollment in a health plan or my eligibility for health benefits. I acknowledge that the information disclosed pursuant to this information may be subject to re-disclosure by the recipient and no longer will be protected by Federal Law. I understand I have the right to revoke this authorization by written notice to the healthcare providers listed on this authorization. I understand that actions taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions. I understand that the information in my medical record may include information relating to treatment of drug or alcohol abuse, mental health, sexually transmitted disease, and acquired immunodeficiency syndrome and human immunodeficiency virus. I understand and agree that there may be costs associated with this request in compliance with State or Federal copying laws._______________________ _______________Patient Signature\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 DateNORTH CAROLINAI certify that ______________________________ personally appeared before me this day, acknowledging to me that he or she voluntarily signed the foregoing authorization for release of medical information.Witness my hand and official stamp or seal, this the _________ day of ___________, _______.____________________Notary Public"},{"@context":"https:\/\/schema.org\/","@type":"BreadcrumbList","itemListElement":[{"@type":"ListItem","position":1,"name":"Blog","item":"https:\/\/www.kregerbrodish.com\/blog\/#breadcrumbitem"},{"@type":"ListItem","position":2,"name":"Free Form Friday: HIPAA Medical Authorization Form","item":"https:\/\/www.kregerbrodish.com\/blog\/free-form-friday-hipaa-medical-authorization-form\/#breadcrumbitem"}]}]