Hipaa Release Form

HIPAA Release

Form

Name:__________________Date of

Birth:___________

Release of Information:

( ) I authorize the release of information including the

diagnosis, records, examination rendered to me and claims

information. The information may be released to:

( ) Spouse/Partner____________________________

( ) Children__________________________________

( ) Other____________________________________

( ) DO NOT RELEASE TO ANYONE

This release will remain in effect until terminated by me in writing.

MESSAGES:

Please call:

( ) my home ( ) my work ( ) my cell

( ) other___________

If unable to reach me:

( ) you may leave a detailed message

( ) leave a message asking me to return your call

( ) ____________________________

Best time to reach me is ___________________.

Signed:_________________________Date:_____________

Employee:______________________Date:______________

0 votes

Parent category: Medical