HIPAA Authorization Form

HIPAA Authorization Form
Name of Child

First NameLast Name
Date of Birth

MonthDayYear
Date
I authorize (healthcare provider) blank to use and disclose the protected health information described below to blank (individual seeking the information).
This authorization for release of information is effective from blanks to blank.
Type of Medical Information to be disclosed

All Medical RecordsAmbulatory Clinic RecordsMedical ConsultationsDischarge RecordsEmergency RecordsMedical History & Physical ExamsImaging ReportsLaboratory & Pathology ReportsOperation ReportsProgress NotesSpeech Therapy/ ABA ReportsPsychological TestsOccupational or Physical Therapy ReportsOther
Name of Parent or Guardian

First NameLast Name
Relationship to Subject
Date Signed

MonthDayYear
Date
Signature of Parent / Guardian

Clear
Should be Empty: