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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.

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.

Download record retrieval user change form (PDF)

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.