Medical Records Disclosure Notes Template

Patient full name: Johnathan Smith  
Date of birth: 15 March 1980  
Medical record number or ID: 123456789  
Authorized releasing party – name: Dr. Emily Johnson  
Authorized releasing party – address/contact: 123 Health St, Springfield, SP1 2AB, Phone: 01234 567890  
Recipient – name: Sarah Smith  
Recipient – relationship to patient: Spouse  
Recipient – address/contact: 456 Elm St, Springfield, SP3 4CD, Phone: 09876 543210  
Description of information to be disclosed: The patient has permitted the release of all medical records related to mental health treatment, excluding any records concerning drug and alcohol treatment. No HIV/AIDS information is to be released.  
Format of disclosure: Electronically via secure portal  
Purpose of disclosure: The disclosure is intended for care coordination purposes as requested by the patient.  
Expiration of authorization: This authorization will expire on 1 November 2025.  
Revocation and rights statement: The patient retains the right to revoke this authorization in writing at any time, except to the extent that action has already been taken based on this authorization.  
Redisclosure limitations and legal protections: The information disclosed may not be redisclosed without the patient's consent, in accordance with state and federal laws protecting patient privacy.  
Signature of patient: Johnathan Smith  
Date of signature: 1 November 2024  
Printed name of patient: Johnathan Smith  
Interpreter name (if applicable): Maria Gonzalez  
Interpreter signature (if applicable): Maria Gonzalez