Medical Information Release Form(HIPAA Release Form)
This form is for authorization to release treatment information.
Email address *
Patient Name *
Your answer
Guardian/Legal Representative Name
Your answer
Relationship to the Patient
Your answer
Date *
MM
/
DD
/
YYYY
Patient DOB *
MM
/
DD
/
YYYY
I authorize the release of information pertinent to my/my child’s treatment including the diagnosis, examination and report, visit notes and claim information. This information may be released to:
Please provide detailed contact information for the person/people you have selected above (Name, phone number, address, and relationship if you selected "other").
Your answer
If you do not want your information released to anyone, select True below.
This Release of Information will remain in effect until terminated by me in writing.
Signature
Today's Date
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