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Medical Release Authorization Form

Hi there. My name is Courtney, and today I’m going to be going over how to obtain medical records that we have in storage at our facility, as well as the proper way to complete the Oklahoma Standard Authorization Form that is required if you are wanting to obtain any protected health information or PHI such as medical records or immunization records. To get a copy of this form, you can either contact us and we can fax or email it to you or you can just go to the state’s website, which is Once you get there, then it’s going to pull up the site that looks like this and you’re just going to scroll down on this sidebar on the left until you get to where it says HIPAA. Select that and then you’ll find all the different forms and you’re just going to locate the Oklahoma Standard Authorization Form.

They do have it in Spanish if you require, but if you select just the main one, then it’s going to pop up in the standard English. So this is what it’s going to look like and once you have this pulled up and you’re going to want to enter in the patient’s name, date of birth and social security number, and that would be for whoever’s records you were actually needing. So if it’s your own records, then when you put your name, date of birth and social. If it’s the information for your child, then you would put the child’s name, date of birth and social there. In the “hereby authorized” section, you’re going to list storage plus and then in the “to release the following information to” section, that is where you’re wanting to list who is actually going to receive the records. So if that’s yourself, then you’d want to put your name and your address right here.

And then if it is for a doctor’s office or a school or military, then you’d want to put the person that’s receiving it and the organization name. It is worth noting though that the name and address of the person that you’re listing does need to match whatever is on their drivers license or whatever government issued photo ID that they’re going to use to pick up the records because it has to match. So after that, then you’re just going to go down to the second section here where it says “information to be shared” and that’s where you’re going to select what it is you’re needing. So if you’re wanting an entire medical record, then you’ll just click this box here. Or if you’re wanting just shot records for instance, then you would click “other” and you would just type in “immunization records.” Then you’ll go down to “the information may be disclosed for the following purposes.”

And typically speaking, most people are just going to select that it’s at their request. But if you have a different reason such as the school’s needing it or a daycare or something like that, then you could just put that in the other section. After that, then you’re going to want to read over these terms and conditions on the form to make sure that you understand what you’re authorizing. And once you’ve done that, then then you can go down to the bottom here and then you’re just going to sign and date it. And the date is just the day that you’re actually signing the form. You don’t need to put it into any kind of advance and then you would just put your name or the legal representative, and if it is a legal representative then you’re going to want to list what their authority is.

So if you’re a caregiver, then you would list something like that in that field. So once you’ve done all of that, it’ll look like this, basically. So you would just have all of that information in there and then we’ll need to get that as well as a copy of the photo ID before we can release the records to you. Once we’ve received that back, then we can determine if we actually have any records in storage that you’re looking for and any costs that might be associated with obtaining those records. And it is worth noting also that if you have multiple people that you were looking to get information from, then you would want a separate form for each person. So if you had multiple children that you’re trying to obtain shot records for, for instance, then you would list a separate one for each child and then we would need all of that back, and then we can get you the information you’re requesting. And that’s pretty much it. So if you have any questions or need any further instructions, please just don’t hesitate to give us a call.

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