1. Patient Information
Document version: records-auth-2026-04-29. This is the source document used by the MedLocker app to generate timestamped signed PDF authorizations.
Full Legal Name
Date of Birth
Phone
Street Address
ZIP Code, City, and State
Last Four of SSN, if requested by the record holder for matching
MedLocker Account Email, if different
2. Personal Representative, if applicable
Representative Name
Relationship or Authority
Phone and Email
Documentation of Authority
- Attached [ ] Already on file [ ] Not applicable
3. Parties Authorized to Disclose Information
I authorize any healthcare provider, health plan, health insurer, health clearinghouse, laboratory, pharmacy, imaging center, dentist, vision provider, behavioral health provider, hospital, clinic, emergency facility, benefits administrator, health information network, QHIN where available, patient portal, EHR vendor, or other person or organization that maintains health, dental, insurance, billing, payment, or related records about me to disclose the information described below to Alpine Labs for my MedLocker account.
4. Recipient
Alpine Labs, Inc., Attn: MedLocker Records Request Team, 15 Highland Meadow Dr, Alexander, NC 28701
Email: records@alpinelabs.ai. Privacy Questions: privacy@alpinelabs.ai
5. Information to Be Disclosed
- Complete Medical Records including physician notes, visit notes, discharge summaries, operative reports, labs, imaging, medications, allergies, immunizations, diagnoses, procedures, care plans, referrals, and related records.
- Complete Dental Records including treatment notes, x rays, periodontal charts, prescriptions, referrals, and dental plans.
- Complete Health Insurance and Claims Records including eligibility, benefits, claims, explanations of benefits, payment history, authorization records, and plan communications.
- Pharmacy Records including prescriptions, fills, refills, medication history, and pharmacy benefit records.
- Billing and Cost Records including bills, charges, payments, and patient responsibility records.
- Other Records specify: ____________________________________________
6. Date Range
- All dates of service.
- Past 1 year.
- Past 3 years.
- Past 5 years.
- Past 10 years.
- Other date range: ____________________________________________
7. Sensitive Categories
Some laws and some record holders require extra permission before releasing certain categories of information. I authorize disclosure of a sensitive category only when I check the category and place my initials beside it. If I leave a category unchecked, that category is withheld under this authorization and should be struck through on the signed PDF. If a provider or law requires a separate authorization, I authorize Alpine Labs to request it from me before collecting that category.
MedLocker keeps my health information private to me unless I choose to share it. MedLocker sharing controls are granular, so I can share only the information I choose while keeping my full history private to my own view.
- [ ] Initials ____ Mental health records, excluding psychotherapy notes unless separately authorized.
- [ ] Initials ____ Psychotherapy notes, if separately permitted and specifically intended.
- [ ] Initials ____ Substance use disorder treatment records, including records subject to 42 CFR Part 2 where applicable.
- [ ] Initials ____ HIV/AIDS, communicable disease, or infectious disease records.
- [ ] Initials ____ Genetic testing information.
- [ ] Initials ____ Reproductive health, fertility, pregnancy, abortion, contraception, or family planning records.
- [ ] Initials ____ Sexually transmitted infection records.
- [ ] Initials ____ Other sensitive records: ____________________________________________
8. Purpose
At my request.
To permit Alpine Labs to obtain, consolidate, store, organize, and maintain my longitudinal health, dental, insurance, and related records in my MedLocker account.
To enable me to view, manage, export, and share my information through MedLocker consent controls.
To support customer service, record quality review, security, and care coordination functions that I request.
To provide optional analytics, insights, summaries, or notifications I elect to receive.
For research, life sciences, analytics, data licensing, compensation, or recontact programs only if I separately consent through MedLocker.
9. Expiration and Revocation
This authorization expires on the earliest of five years from signature, the date or event specified here: ____________________________________________, or the date Alpine Labs receives and processes my written revocation.
I may revoke this authorization at any time by contacting privacy@alpinelabs.ai or through available MedLocker controls. Revocation stops future records requests under this authorization. It does not automatically delete records already received by MedLocker, which are governed by the Privacy Policy, deletion controls, and applicable law.
10. Redisclosure Notice
I understand that once my information is disclosed to Alpine Labs for my MedLocker account, Alpine Labs may not be a HIPAA Covered Entity or Business Associate for this consumer directed records request. As a result, HIPAA may no longer govern Alpine Labs handling of the information. Alpine Labs will protect my information under its Privacy Policy, Terms of Service, my consent choices, and applicable federal and state privacy and consumer protection laws.
Alpine Labs may redisclose my information only as I direct through MedLocker, as permitted by separate consent, to service providers supporting MedLocker under confidentiality and security obligations, or as required by law.
11. Voluntariness, Fees, and Special Law Notices
I understand that my healthcare providers, health plans, insurers, and other record holders may not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this authorization, except as permitted by law. Some record holders may charge fees as permitted by law. State and federal laws may provide additional protections for certain information, including mental health, substance use disorder treatment, HIV/AIDS, genetic, reproductive health, STI, minor, and insurance information.
12. Electronic Signature and Copies
A photocopy, fax, scan, image, or electronic version of this authorization is as valid as the original. If I sign electronically, I agree that my electronic signature has the same legal effect as a handwritten signature to the extent permitted by law.
Questions may be directed to Alpine Labs at privacy@alpinelabs.ai.
Signature
Signature
Printed Name
Date
Representative Name, if applicable
Relationship or Authority
Internal Use Only
Record Request ID ____________________ Verified ID [ ] Processed By ____________________ Date Processed __________
Notes ________________________________________________________________________