Authorization For Release Of Medical Records

• Date: 2024-05
• Legal Form Number: BP-A0621
• Year: 2024
• Section: Federal Bureau of Prisons

PDFPrescribe by P6031

Page 1 of 1

BP-A0621 AUTHORIZATION FOR RELEASE OF MEDICALRECORDS

MAY 24

U.S. DEPARTMENTOF JUSTICEFEDERAL BUREAU OF PRISONS

COMPLETE ALL SECTIONS, DATE, AND SIGN

I.

(PRINT) Full Legal Name

(Last, First, Middle)

:

Other Names(Maiden Name, Alias):

Register Number

Date of Birth

II.Pursuant to 5 U.S.C. Section 552a (b), I authorize the U.S. Department of Justice to:

☐Obtain information fromOR☐Release information to

Name of Person/Facility:

Phone:

Fax:

Address:

City/State/Zip Code:

III.Purpose of Disclosure: ☐Continuing Care ☐Disability Determination ☐Legal☐ Other: _____________________

IV.Information to be Released/Obtained: Copy of and/or information from my health recordpertaining to my

evaluation/treatment received from__________________to___________________.

☐

Complete Record

☐

Laboratory Reports

☐

Pathology Reports

☐

Radiology Reports

☐Consultations

☐Medication List

☐Pathology Slides

☐Will be returned OR

☐

Duplicates accepted

☐Radiology Film/Imaging

☐Will be returned OR

☐

Duplicates accepted

☐

Discharge Summary

☐

Operative/Procedure

☐History & Physical

☐Progress Notes

☐Immunization Record

☐Other:

I authorize the release of the following sensitive information relating to:

☐Alcohol/Drug Treatment/Referral☐HIV/AIDS Treatment

☐Behavioral/Mental Health (Other than Psychotherapy Notes )☐Sexually Transmitted Diseases

Signature of Patient: Date:

Signature of Witness/Credentials (If required):Date:

(Print) Witness Name/Credentials:

DEPARTMENT USE ONLY

Processed by: __________________ Date: __________ Requested by: __________________☐No health records found

Mail or fax records to:

V.Privacy Act Statement. In accordance with 28 CFR Section 166.41(d) personal data sufficient to identify the

individuals’submitting requests by mail under the Privacy Act of 1974, 5 U.S.C. Section 552a, is required. The

purpose of this solicitation is to ensure that the records of individuals who are the subject of US Department of

Justice systems of records are not wrongfully disclosed by the Department. Failure to furnish this information will

result in no action being taken on the request. False information on this form may subject the requester to criminal

penalties under 18 U.S.C. Section 1001 and/or 5 U.S.C. Section 552a (i)(3).

I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and

correct, and that I am the person named above, and I understand that any falsification of this statement is

punishable under the provisions of 18 U.S.C. Section 1001 by a fine of not more than $10,000 or by imprisonment

of not more than five years or both, and that requesting or obtaining any record(s) under false pretenses is

punishable under the provisions of 5 U.S.C. 552a(i)(3) by a fine of not more than $5000.

I understand that authorizing the disclosure of this health information is voluntary and not a condition of treatment. I

understand that information used or disclosed pursuant to this authorization could be subject to re-disclosure by the

recipient and, if so, may not be subject to federal or state law protecting its confidentiality. I understand that I may

revoke this consent at any time by sending a written notice to the Supervisor of Medical Records. I understand that

any release which has been made prior to my revocation and which was made in reliance upon this authorization

shall not constitute a breach of my rights to confidentiality. This authorization will automatically expire 90 daysfrom

the date of the signature.

I understand that my substance use disorder records are protected under the Federal regulations governing

Confidentiality and Substance Use Disorder Patient Records, 42 C.F.R. Part 2, and cannot be disclosed without my

written consent unless otherwise provided for by the regulations.