Release of Information Form

HIPAA Authorization for Release of Information

Elizabeth Dodd,LMBT Diligent Medical Massage
I, the patient listed below, hereby authorize Diligent Medical Massage, LLC. and Elizabeth Dodd, LMBT to release the Personal Health Information (PHI) indicated below to the person or organization listed below.
Name

First NameMiddle NameLast NameSuffix
Birth Date

MonthDayYear
Email
example@example.com
Last 4 SSN
Type of Information to be Released
Purpose for Information Release
(List as specifically as possible, for example: to receive benefits, auto accident or worker's comp claim, another doctor or family need, etc.).
Is This Release a Result of an Accident or Injury?
If Yes, Please Indicate the Date of Loss, Accident or Injury

MonthDayYear
Date
If Yes, Please Indicate the Party or Organization Responsible
Insurance Co, Employer, Individual, ETC
Release Information to the Following

Please fill out the fields below to the best of your knowledge to ensure your PHI is protected and released to the correct individual or organization.
Name

First NameMiddle NameLast NameSuffix
Organization
Company, Law Firm, Doctor, Family Member, ETC)
Phone Number
Email Address
Delivery Method of Authorized PHI (Reimbursement Charges MAY Apply for Mail or Overnight Except on Medical Liens)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please Indicate Recipient Type of Disclosure

Other
Please Indicate Desired Length of Disclosure
Release Date Expiration

MonthDayYear
Date
Consent
Are You Signing This Release on Behalf of a Minor Child or as a Guardian?
*Digital Signatures: In 2000, the U.S. Electronic Signatures in Global and National Commerce (ESIGN) Act established electronic records and signatures as legally binding, having the same legal effects as traditional paper documents and handwritten signatures. Read more at the FTC website: http://www.ftc.gov/os/2001/06/esign7.htm
Signature of Patient
Signature of Parent or Guardian
Should be Empty:

HIPAA Authorization for Release of Information

Release Information to the Following