Crosspointe HIPAA Medical Release Form

Crosspointe HIPAA Form
HIPAA Privacy Practices Authorization to Release Medical Information To Family Members/Friends

I understand that under the Notice of Privacy Practices that my health information must be released only to me unless I have authorized release to a family member, friend or other persons.
I, (patient name) blanks give Crosspointe Medical Clinic and it's Physicians authorization to release my medical Information to :
Name

First Name Last Name
Relationship
Phone Number
Please enter a valid phone number.
Name

First Name Last Name
Relationship
Phone Number
Please enter a valid phone number.
Name

First Name Last Name
Relationship
Phone Number
Please enter a valid phone number.
I understand this authorization will remain in effect until I notify your office in writing of my intent to stop authorization.
Name

First Name Last Name
Date of Birth

Month Day Year
Date
Signature

Clear
Date Signed

Month Day Year
Date
Witness

First Name Last Name
Date

Month Day Year
Date
Should be Empty:

Crosspointe HIPAA Form