Authorization for Release of Protected Health Information Form Logo
  • 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 * 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:

  • Section III

    Reason for Disclosure
  • Patient Information

    Contact and incident information of Patient.
  • 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)

  • 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:

  •    The date of the signature in section VI until the following event:   
      From   Pick a Date   to   Pick a Date   
      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
  •  - -
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  • 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:

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