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Basic HIPAA Release Form

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
[ ] 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.
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