Authorization for Release of Protected Health Information Form

Authorization for Release of Protected Health Information Form
Please complete all sections of this HIPAA release form. If any sections are left blank, this form will be invalid and it will not be possible for your health information to be shared as requested.
Section I
I PATIENT NAME* give my permission for FIRST AID SERVICES, LLC. to share the information listed in Section II of this document with the person(s) or organization(s) I have specified in Section IV of this document.
Section II

Health Information
I would like to give the above healthcare organization permission to:
Consent to release of health information:*

Disclose my complete health record including, but not limited to, diagnoses,lab test results, treatment, and billing records for all conditions.Disclose my complete health record except for the following information:
Health information*
Please provide details of what kind of health information you would NOT like to share or disclose.
Form of Disclosure

Electronic copy or access via a web-based portalHard copy
Section III

Reason for Disclosure
Please detail the reasons why information is being shared. If you are initiating the request for sharing information and do not wish to list the reasons for sharing, write ‘at my request’.
Patient Information

Contact and incident information of Patient.
Name of Patient*

First NameLast Name
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Email*
example@example.com
Patient Phone Number*
Please enter a valid phone number.
Date or Event*
Provide the date of the actual medical incident
Name of Event *
At what event did the patient receive medical care at from First Aid Services
Section IV

Who Can Receive My Health Information
I give authorization for the health information detailed in section II of this document to be shared with the following individual(s) or organization(s)
Entity/Name *
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
I understand that the person(s)/organization(s) listed above may not be covered by
state/federal rules governing privacy and security of data and may be permitted to further share the information that is provided to them.
Section V

Duration of Authorization
This authorization to share my health information is valid:
1.   The date of the signature in section VI until the following event:   Type a label
2.   From   Date   to   Date
3.   All past, present, and future periods
I understand that I am permitted to revoke this authorization to share my health data at any time and can do so by submitting a request in writing to:

FIRST AID SERVICES, LLC

4238 SPRING COURT

LA MASA CA 91941

I understand that:

1. In the event that my information has already been shared by the time my
authorization is revoked, it may be too late to cancel permission to share my health
data.

2. I understand that I do not need to give any further permission for the information
detailed in Section II to be shared with the person(s) or organization(s) listed in section IV.

3. I understand that the failure to sign/submit this authorization or the cancellation of
this authorization will not prevent me from receiving any treatment or benefits I am
entitled to receive, provided this information is not required to determine if I am
eligible to receive those treatments or benefits or to pay for the services I receive.
Section VI

Signature
Date Signed*

MonthDayYear
Date
Signature

Clear
Name of Patient (Releasor)*

First NameLast Name
If this form is being completed by a person with legal authority to act an individual’s behalf, such as a parent or legal guardian of a minor or health care agent, please complete the following information:
Name of person completing this form:

First NameLast Name
Signature of person completing this form:

Clear
Describe below how this person has legal authority to sign this form:
Upload Proof of Identity*

Cancelof
Type of Identification*
Identification Number*
Should be Empty:

Authorization for Release of Protected Health Information Form

Section I

Section II

Section III

Patient Information

Section IV

Section V

Section VI