Home > Legal > Release Template > HIPAA Release Template > Basic HIPAA Release Template

Basic HIPAA Release Form

At Speedy Template, You can download Basic HIPAA Release Form . There are a few ways to find the forms or templates you need. You can choose forms in your state, use search feature to find the related forms. At the end of each page, there is "Download" button for the forms you are looking form if the forms don't display properly on the page, the Word or Excel or PDF files should give you a better reivew of the page.

Basic HIPAA Release Form
Basic HIPAA Release Form
Medical Information 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. This information may be released
to:
[ ] Spouse________________________________________
[ ] Child(ren)______________________________________
[ ] Other__________________________________________
[ ] Information is not to be released to anyone.
This Release of Information will remain in effect until terminated by me in writing.
Messages
Please call [ ] my home [ ] my work [ ] my cell Number:__________________
If unable to reach me:
[ ] you may leave a detailed message
[ ] please leave a message asking me to return your call
[ ] __________________________________________
The best time to reach me is (day)___________________ between (time)_________
Signed: ______________________________________ Date: ____/____/_____
Witness:______________________________________ Date: ___/____/______
Basic HIPAA Release Form