HIPAA

HIPAA Privacy Authorization Form
Patient Name:

First NameLast Name
Date of Birth

MonthDayYear
I, hereby authorize Pain Care Physicians to release any and all medical information and test results that pertain to me, to the following individuals. Please include Full Name, Phone # and Relationship to patient.
I, hereby authorize Pain Care Physicians to release any and all medical information and test results that pertain to me, to the following individuals. Please include Full Name, Phone # and Relationship to patient.
I, hereby authorize Pain Care Physicians to release any and all medical information and test results that pertain to me, to the following individual(s). Please include Full Name, Phone # and Relationship to patient.
I authorize Pain Care Physicians to contact the individuals(s) listed above to convey any pertinent information to me, in the event that I am unable to be reached by facility. I undertand that I may revoke/ cancel this authorization by notifying Pain Care Physicians in writing of my intent to revoke authorization or change the name(s) of the individuals to whome information is being released.
Signature of Patient
Date

MonthDayYear
Date
Should be Empty:

HIPAA Privacy Authorization Form