Hipaa - Compliant Release Form (Authorization For Disclosure Of Protected Health Information) Page 2

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I have had the opportunity to read and consider the contents of this authorization. I confirm that the contents
are consistent with my direction, and that a photocopy of this 2-page form is as valid as the original to allow
release of my records.
____________________________________
_________________________
Signed
Date
Name: __________________________________________________________________________
Address: ________________________________________________________________________
City: ___________________________________ State: _______ Zip: _________________
Telephone: _____________________
D.O.B.: ________________________
Social Security Number: __________________ Check here if SS# is for minor child
_____________________________________________________________
Relationship or Authority of Personal Representative (if applicable)
1
Protected health information (PHI) is health information that is created or received by a health care provider,
health plan, or health care clearinghouse which relates to: 1) the past, present, or future physical or mental
health of an individual; 2) the provision of health care to an individual; or 3) the past, present, or future
payment for the provision of health care to an individual. To be protected, the information must be such that it
identifies the individual or provides a reasonable basis to believe that the information can identify the
individual. 45 C.F.R. 164.508.
2
These laws apply to health plans, health care providers, and health care clearinghouses

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