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Forms
Here are some common forms you may need to fill out in order to give authorization to access your medical information.
Patient authorization
This medical record information release (HIPAA) form allows patients to give authorization to a third party to access their health records and allows your healthcare provider to share your health information.
Important: Some health systems have customized forms that are not listed on this page. If you have questions about a form, call your doctor’s office.
English language release form
HIPAA Form H004-2010.1
Patient authorization for release of medical records for continuity of care.Spanish language release form
HIPAA Form H004-2010.1
Autorización del paciente para divulgación de expedientes médicos para la continuación de atención médica.Hospital system specific authorization forms
You can find patient authorization forms for specific facilities below.
To expedite the process, please make sure you:
- PRINT the full name of the person seeking care
- SIGN and DATE the form
- FAX or MAIL the form to: 866-920-5565 or eHealth Technologies, 500 WillowBrook Office Park, Suite 500, Fairport, NY 14450.
- eHealth Technologies Patient Authorization Form
- eHealth Technologies Clinical Trials/Right to Access Patient Authorization Form
- Record Retrieval User Change Form (PDF)
- Columbia University Department of Anatomic Pathology: Authorization to Release Medical Information
- Columbia University Medical Center: Authorization to Release Medical Information
- Hinge Health: Authorization to Release Medical Information
- John Hopkins Hospital: Authorization to Release Medical Information
- Mayo Clinic: Authorization to Release Protected Health Information
- Mindstrong Health: Gabe Aranovich, MD
- Mount Sinai Medical Center: Patient Authorization for Release of Medical Information
- National Institute of Health: Authorization for the Release of Medical Information
- New York City Health and Hospitals Corporation (NYCHHC): HIPAA Authorization to Disclose Health Information
- NewYork-Presbyterian Hospital: Authorization Form to Disclose Protected Health Information/Medical Records (English)
- NewYork-Presbyterian Hospital: Authorization for the Release of Medical Information and Acknowledgement of Responsibility (English)
- Northwestern Memorial Hospital Patient Authorization for Release of Medical Information
- NYU Langone Medical Center: Authorization for Release of Protected Health Information (PHI)
- Oschner Medical Center: Authorization for Release of Confidential Information (English) and Authorization for Release of Confidential Information (Spanish)
- Thomas Jefferson University: Consent to Release Medical Information
Clinical trials
This clinical trial release form allows patients to give authorization to a third party to access their health records and allows your healthcare provider to share your health information.
Clinical trials / right to access patient authorization form
HIPAA Form H004-2023
Patient authorization for release of medical records for patient right to access.
Complete the clinical trials/right to access patient authorization form
User change request
Complete this form to add or delete an eHealth Connect user from your facility.
Record retrieval user change form
eHealth Connect® Intelligent Health Record Aggregation user change form
Patient authorization for release of medical records for continuity of care.
Have additional questions?
Whether you are a health system looking to improve your patient throughput, a health information exchange user looking to connect image studies, or a clinical research organization looking to organize your patients’ medical information, we want to work with you to help you achieve your mission to improve patient outcomes.