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DOB: -  ·  MRN: -

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Providers at your clinic who see this patient. Add as many as apply β€” pick from the list, or type a name and press Enter.

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Your morning action list β€” prioritized by urgency

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Set up automatic follow-up for record requests and referrals

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Follow up if no appointment scheduled
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Request results after appointment date

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last 30 days

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Detail

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HIPAA Authorization
Signed electronically • Ref:

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION

Pursuant to 45 CFR Β§164.508 (HIPAA)

Patient Information
Full Legal Name
β€”
Date of Birth
β€”
Insurance Provider
β€”
MRN
β€”
Authorization

I authorize my healthcare provider and any prior treating physicians, hospitals, clinics, or health plans to disclose my protected health information to:

Requesting Organization
Ownity Health / Requesting Clinic
records@ownityhealth.com • (800) 555-0190

Purpose: Continuity of care β€” to obtain prior medical records in advance of an upcoming appointment on β€”.

Records authorized for release:

✓ Office visit notes ✓ Lab results ✓ Imaging & radiology ✓ Medication history ✓ Procedure reports ✓ Specialist referrals
Patient Rights

• I understand I may revoke this authorization at any time by contacting Ownity Health in writing, except where action has already been taken in reliance on this authorization.

• I understand that signing this authorization is voluntary and that my treatment is not conditioned upon signing.

• I understand that information disclosed may be subject to re-disclosure and no longer protected by HIPAA.

• This authorization expires one year from the date of signature or upon fulfillment of the records request, whichever comes first.

Electronic Signature
Patient Signature
β€”
Date Signed
β€”
Signed Via
E-signature • Ownity intake portal
IP Address
192.168.1.42

This authorization was collected in compliance with 45 CFR Β§164.508 of the Health Insurance Portability and Accountability Act (HIPAA). A copy of this signed authorization has been provided to the patient and is retained on file by Ownity Health.

Ownity Found Additional Records

While processing records from , Ownity identified provider(s) not yet in ’s request list.

Discovered by analyzing incoming record references • Review before sending