Medical Information Release Form (Hipaa Authorization)

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Medical Information Release Form
(HIPAA Authorization)
Patient: _______________________________________ Date of Birth: _____________________
Partner: _______________________________________ Date of Birth: _____________________
Release of Information
By signing below, I authorize the following medical provider to disclose certain protected health
information about me (or my Partner, if applicable) to Parental Hope, Inc. for the purpose of applying
for the Parental Hope Family Grant.
Name of Medical Provider:___________________________________
Address:_________________________________________________
Physican:_________________________________________________
This Release of Information will remain in effect until terminated by me in writing.
Signature of Patient:____________________________________ Date: _____________________
Signature of Partner:____________________________________ Date:______________________
Witness:______________________________________________ Date:______________________

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