HIPAA Authorization Form
Date today
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Name
First Name
Last Name
Date of Birth
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age
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Indefinitely or until I say otherwise
Allowed Purpose of Disclosure of Information
Indicate the purpose of disclosure (e.g. For coordination of treatment, personal reasons, medical procedure, etc. all acceptable)
Please list other Person(s)/Facility Permitted to see/discuss PHI(Personal Health Information) on your behalf
Who we can share your information with (Ex: Sister, Therapist, Primary Care Doctor etc.)
Type of Medical Information to be disclosed:
All Medical Records
Ambulatory Clinic Records
Medical Consultations
Dental Records
Discharge Records
Emergency Records
Financial Records
Medical History & Physical Exams
Imaging Reports
Laboratory & Pathology Reports
Operation Reports
Progress Notes
Psychological Tests
Other
Other Information allowed to be disclosed
I give consent to the release of my HIV/AIDS testing information if there is any
I give consent to the release of information pertaining to drugs and alcohol
I give consent to the release of my genetic information and family background information
I give consent to the release of information pertaining to mental health diagnosis or treatment.
Signature of Patient /Subject
Date Signed
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If Patient is a minor or has a legal guardian
*Otherwise you may skip this part and hit the submit button.
Name of Parent or Guardian
First Name
Last Name
Relationship to Subject
Signature of Parent/Guardian
Date Signed
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Submit
Should be Empty: