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*

Both SOAP Notes (Medical Record or Chart) and Billing & Account InformationSOAP Notes OnlyBilling & Account Information Only
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?*

YesNo
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)*

Electronic (Email/Fax)Mail (USPS, UPS, FedEx)Express Overnight ServiceAny
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please Indicate Recipient Type of Disclosure*

Continued Medical Care to Another Doctor or PracticeLegal PurposesInsurance PurposesPersonal InterestOther
Please Indicate Desired Length of Disclosure*

Disclose IndefinitelyDisclose Until Date Indicated Below
Release Date Expiration

MonthDayYear
Date
Consent*

I understand that this release is valid when I sign it and that I may withdraw my consent to this release at any time either orally or in writing.
Are You Signing This Release on Behalf of a Minor Child or as a Guardian?*

YesNo
*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*

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Signature of Parent or Guardian*

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Should be Empty:

HIPAA Authorization for Release of Information

Release Information to the Following