HIPAA Authorization Form
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date today
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
age
Consent for Disclosure to:
(Family member name, family doctor name)
Person Allowed to Disclose Information
Prefix
First Name
Last Name
Suffix
Type of Medical Information to be disclosed
All Medical Records
Medical Consultations
Financial Records
Medical History & Physical Exams
Operation Reports
Progress Notes
Other
Other Information allowed to be disclosed
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.
Patient Signature
Date Signed
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Parent or Legally Authorized Representative
In case the subject is beyond the legal age of consent:
Name of Parent or Guardian
First Name
Last Name
Relationship to Subject
Signature of Parent / Guardian
Date Signed
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: