Form Hipaa-12 - Authorization Form For Release Of Health Information Page 3
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3AUTHORIZATION FORM FOR RELEASE OF HEALTH INFORMATION
4. By authorizing this release of information, my healthcare and payment for my healthcare will not be affected if I do not
sign this Authorization form.
5. I have been offered a copy of this signed Authorization form.
_______________________________________
_____________________
SIGNATURE OF PATIENT
DATE
OR
__________________________________________
____________________
PARENT/LEGAL GUARDIAN/AUTHORIZED PERSON
DATE
FOR OFFICE USE ONLY
DATE REQUEST FILLED: ________________ BY: ____________________
FORM OF IDENTIFICATION PRESENTED: ______________________
HIPAA-12 (9/1/16)
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