Medical Information Release Form printable pdf download

Medical Information Release Form

Anant Kumar, MD, MS

Medical Information Release Form

(HIPAA Release Form)

Name: ___________________________________ Date of Birth: _____/____/_____

Patient Disclosure Record

In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and

disclosures of their protected health information (PHI). The individual is also provided the right to

request confidential communications, or that a communication of PHI be made by alternative means,

such as sending correspondence to the individual's office instead of the individual's home.

[ ] Patient Initials (I have read the above policy)

Release of Information

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

and claims information. This information may be released to:

[ ] Spouse________________________________________

[ ] Child(ren)______________________________________

[ ] Other__________________________________________

[ ] Information is NOT to be released to anyone.

Contact Information

Please call:

[ ] Cell number

[ ] Home number

[ ] Work number

If unable to reach me:

[ ] Leave a detailed message

[ ] Leave a message asking me to return your call

[ ] __________________________________________

Written Correspondence:

[ ] Home address

[ ] Work address

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

Signed: ______________________________________ Date: ___________________

Medical Information Release Form