Hipaa Release Form printable pdf download

Hipaa Release Form

Medical Information Release Form (HIPAA Release Form)

Name:________________________________________ Date of Birth___________

Release of Information

I authorize the release of information including the diagnosis, records; examination rendered to

me and claims information. This information may be released to:

Spouse:___________________________________________________

Child(ren):_________________________________________________

Employer:_________________________________________________

Other:____________________________________________________

Information is NOT to be released to anyone.

The Release of Information will remain in effect until terminated by me in writing.

Messages

Please call:

My home

My work

My cell phone ____________________

If unable to reach me:

You may leave a detailed message

Please leave a message asking me to return your call

Other______________________________________

The best time to reach me is (day)_______________ between(time)__________

Signed___________________________________ Date_________________

Witness__________________________________ Date_________________

OUCH Urgent Care, LLC 2016

Hipaa Release Form