Medical Information Release Form (Hipaa Release Form) printable pdf download

Medical Information Release Form (Hipaa Release Form)

Department of Medicine

Division of Gastroenterology and Hepatology

UNC Liver Program

Medical Information Release Form (HIPAA Release Form)

Name: _____________________________ Date of Birth:____/__/___ MR#_____________

Release of Information

I authorize the release of information including the diagnosis, records, examination results,

medication dose changes, and claims information.

This information may be released to:

[ ] Information is not

[ ] Spouse________________________________________

to be released to

[ ] Child(ren)______________________________________

anyone other than me.

[ ] Other__________________________________________

Messages

Please call [ ] my home ph#________________

[ ] my cell ph#__________________

If unable to reach me:

[ ] Do not leave

[ ] you may leave a detailed message

messages on my

phone mailbox.

[ ] please leave a message asking me to return your call

The best time to reach me is (day of week)___________________ between (time)_________

E-mail Messages

[ ] Use my e-mail address to send messages for me to contact the nurse for information

[ ] Use my e-mail to leave detailed messages and information.

[ ] Attach lab results to the e-mail message.

My e-mail address is ____________________________________________

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

This release specifically excludes any psychiatry and psychology evaluations/records which are

further restricted by HIPAA regulations.

Patient: ______________________________________ Date: ____/____/_____

Witness:______________________________________ Date: ___/____/______

6Mar2013/rev29May2013

Medical Information Release Form (Hipaa Release Form)