I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form:. To be valid, a HIPAA authorization must satisfy the following.On the top Enter your information where the boxes ask for Patient Name, Date of. Birth, Social Security Number and Patient Address. HIPAA allows certain disclosures without the patient's written authorization, including disclosures to other providers or third party payers. You are under no obligation to authorize your parents access to your medical records. To request a copy of your medical records: Fill out the Medical Record Authorization Release form, click on the link below to download. How do I fill out a HIPAA release form? The Patient Record Request Tool is to assist you in generating and sending a signed pdf Record Request form to Myriad Medical Records. Use this form to request a copy of your medical records.