HIPAA Authorization Form
Name
First Name
Last Name
Date of Birth
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Month
-
Day
Year
Date
Date today
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Month
-
Day
Year
Date
age
Date From
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Month
-
Day
Year
Date
Date To
-
Month
-
Day
Year
Date
Allowed Purpose of Disclosure of Information
Indicate the purpose of disclosure (e.g. For research, for sponsorships, further development of study)
Person Allowed to Disclose Information
Prefix
First Name
Last Name
Suffix
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.
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Signature of Patient / Subject
Date Signed
-
Month
-
Day
Year
Date
Submit
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Next
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
Date
Submit
Should be Empty: