Medical Records Release Authorization

Secure & Encrypted — NPConnect Telehealth

This form authorizes NPConnect to release your protected health information (PHI) to the individual or organization specified below. You have the right to revoke this authorization at any time in writing, except where action has already been taken. This form is completed on an as-needed basis and is not required for routine care.

Fill in all sections and sign at the bottom

Patient Information

Full Legal Name *

Date of Birth *

Email Address *

Phone Number

Authorize Release To

Name of Person / Organization *

Address

Phone

Fax

Records to be Released *

Office Visit Notes / Progress Notes

Laboratory Results

Imaging Reports (X-ray, MRI, CT, etc.)

Hospital Discharge Summary

Medication List / Prescription History

Immunization Records

Referral Letters

Entire Medical Record

Date Range — From

Date Range — To

Purpose of Disclosure *

Continuing Medical Care

Personal Use

Insurance / Legal Purposes

Specialist Referral

Other

Preferred Delivery Method

Secure EmailFaxUS MailPatient Pickup (Electronic Copy)

Important Notices

By signing this form, I authorize NPConnect to release the records described above. I understand that:

I may revoke this authorization at any time in writing, except where NPConnect has already acted upon it.
My treatment at NPConnect is not conditioned upon signing this authorization.
Information disclosed pursuant to this authorization may be re-disclosed by the recipient and may no longer be protected by HIPAA.
This authorization expires one (1) year from the date of signature unless I specify a different date below.
NPConnect may charge a reasonable fee for copying and mailing records as permitted by applicable law.

I have read and understand the above notices and voluntarily authorize the release of my medical records as described.

Patient Signature

Sign below to authorize this release. This electronic signature is legally binding.

Signature *

Draw your signature in the box above

Date: October 23, 2026

All required fields, at least one record type, a purpose, the acknowledgement, and your signature are needed before submitting.