Fillable Printable Medical Information Release Form - HIPAA

Medical Information Release Form - HIPAA

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: ___/____/______