Hipaa Release Form
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1John M. Keggi, M.D.
Robert E. Kennon, M.D.
HIPAA RELEASE FORM
Name: _______________________________
Date: ______________________
Privacy regulations require us to have releases signed by our patients for us to speak with family
members, friends and other relations regarding medical treatment. Each person must be listed
individually and by name.
Please print name, relationship and telephone number for each person to whom you are authorizing
release of your private health care information.
_____________________________ ________________________
_______________________
Name
Relationship
Telephone #
_____________________________
________________________
_______________________
Name
Relationship
Telephone #
_____________________________ _________________________
_______________________
Name
Relationship
Telephone #
Under the new Federal Health Care Law of 2011, we have been asked to request the following
information from you. Email address: ___________________________________________________
Gender: □ Female □ Male
Language (check one):
Race (check one):
□ Cantonese
□ Polish
□ American Indian
□ English
□ Portuguese
□ Indian
□ French
□ Russian
□ Asian
□ German
□ Spanish
□ Black or African American
□ Italian
□ Vietnamese
□ Hispanic or Latin American
□ Japanese
□ Not Identified
□ Native Hawaiian
□ Mandarin
□ Other: ________________
□ White
□ Other: _______________
Ethnicity (check one):
□ Multiracial
□ Not Identified
□ Not Identified
□ Hispanic or Latino
□ Declined to Specify
□ Not Hispanic
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