Hipaa Release Form printable pdf download

Hipaa Release Form

HIPAA RELEASE FORM

Patient Name: _____________________ Medical Record #: ________________

Privacy regulations require us to have a release signed by our patients so we may speak with

family members, friends and other relations regarding your medical treatment and patient

financial information. Each person you wish to be considered a contact must be listed

individually by name (including a Spouse or Significant Other).

Please print name, relationship and telephone number for each person to whom you are

authorizing release of your private health care information and account balances.

_____________________________________

_____________

______________

Name

Relation

Phone #

_____________________________________

_____________

______________

Name

Relation

Phone #

_____________________________________

_____________

______________

Name

Relation

Phone #

_____________________________________

_____________

______________

Name

Relation

Phone #

This authorization will expire on: ____/____/____ (fill in date if less than 1 year) or one year

after being signed.

__________________________________________

________________________

Patient Signature

Date

Hipaa Release Form