Authorization Forms Library
In order to facilitate a patient's access to continuity of medical care, we are happy to provide this library of links to various authorization forms for the release of protected health information from healthcare facilities across the United States. eHealth Technologies is not affiliated with these healthcare facilities and as such is not responsible for the content of these forms. If you experience any broken links, please e-mail us at info@ehealthtechnologies.com. To ensure that your protected health information is safeguarded at all times consistent with Privacy and Security obligations, please DO NOT e-mail completed forms to this e-mail address.
To expedite the process, please make sure you:
1) PRINT the full name of the person seeking care
2) SIGN and DATE the form
3) FAX or MAIL the form to: 866-920-5565 or eHealth Technologies, 250 Thruway Park Drive, West Henrietta, NY 14586
Authorization Forms links:
- opens in a new windowColumbia University Medical Center: Authorization to Release Medical Information
- opens in a new windowMayo Clinic: Authorization to Release Protected Health Information
- opens in a new windowMindstrong Health – Gabe Aranovich, MD
- opens in a new windowMount Sinai Medical Center: Patient Authorization for Release of Medical Information
- opens in a new windowNew York City Health and Hospitals Corporation (NYCHHC): HIPAA Authorization to Disclose Health Information
- opens in a new windowNewYork-Presbyterian Hospital: Authorization Form to Disclose Protected Health Information/Medical Records (English)
- opens in a new windowNYU Langone Medical Center: Authorization for Release of Protected Health Information (PHI)
- opens in a new windowThomas Jefferson University: Consent to Release Medical Information