Media Release Authorization Form - HIPAA Release of Information
Please specify which of your medical conditions we may publish about (this will include all accompanying treatments and healthcare services):
The following information about me will not be disclosed:
I specify no limitations in disclosure of any of my information at this time.
Other
This authorization is valid from the date of my or my legal representative’s signature below and shall expire on:
I specify no expiration date of the media information release at this time.
Other
Signature:
*
If you are signing for the patient, please answer the following:
I am permitted to sign for the patient as I am their legal guardian/medical power of attorney/decision maker.
My name is
First Name
Last Name
,
and my relationship to the patient is
.
Patient's Name:
*
First Name
Last Name
Patient's Date of Birth (MM-DD-YYYY):
*
Today's date (MM-DD-YYYY):
*
Submit
Should be Empty: