Medical Information Release Form printable pdf download

Medical Information Release Form

(HIPAA Release Form)

Patients Name:__________________________________ Date of Birth:___/___/____

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

me and claims information.All responsible parties on the account, including insurance

cardholders, must be listed below (PLEASE PRINT NAMES):

( ) Spouse________________________________________________

( ) Child(ren)______________________________________________

( ) Parent(s)______________________________________________

( ) Other_________________________________________________

( ) Information is not to be released to anyone

The best contact number I can be reached on/at:

( )My home______________________________

( ) My Work______________________________

( ) My Cell________________________________

A detailed message may be left on my voicemail ( ) Yes ( ) No

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

Patient or Guardian Signature: ____________________________________ Date: ___/___/____

Relationship to the patient if a minor: ______________________________

Witness: ______________________________________ Date:___/___/____

Medical Information Release Form