Style 5 Demo

Authorization for Release of Information

Let us share your health information with someone you choose.

Authorization to release health information

Use this form to let us share your health information with someone you choose, such as another provider, an insurer, a lawyer or a family member. We don't need this form to share information with other providers who are treating you.

Patient Name *

Email *

Date of Birth *

Who may release the information (person or organization) *

Who may receive the information (name, organization and address) *

What information may be released *

Describe the dates or the records (for example, X-rays from 2025, or visit notes from March 2026) *

Some information has extra legal protection (for example, substance use disorder treatment records, HIV or genetic test results). If your request includes it, we may need a more specific authorization and will contact you before releasing it. Psychotherapy notes can't be released with this form; ask us for a separate authorization.

Purpose of the release (you may write "at my request") *

This authorization ends *

On a date

When an event happens

End date *

The event that ends it (for example, "when my claim is settled") *

You may revoke this authorization at any time by writing to Style 5 Demo, except for information already released because of it.

Your treatment, payment, enrollment or eligibility for benefits will not depend on whether you sign this authorization.

Information released under this authorization may be shared again by the person who receives it and may no longer be protected by federal privacy law.

You may refuse to sign this authorization, and you are entitled to a copy of it.

Who is signing this form? *

Patient (myself)

Parent or legal guardian

Other legal representative

Your full name *

Your authority to sign for the patient (for example, parent, court-appointed guardian or health care power of attorney) *

By signing below, you confirm the information you gave is accurate to the best of your knowledge and you agree to sign this form electronically. Your electronic signature has the same effect as a handwritten one. You can ask Style 5 Demo for a paper copy of this form at any time.

Date *

Signature *

Your information is encrypted and transmitted securely under HIPAA.

← Back to Forms