HIPAA Consent Form

HIPAA Consent and Medical Release Form

(for patients 18 years and older)
Patient Name*
Date of Birth*

MonthDayYear
Date
Phone Number*
Email Address*
example@example.com
Please select one:

I grant FULL access to my parents and/or guardians regarding my medical information in order to provide assistance with my healthcare needs.I grant PARTIAL access to my parents and/or guardians regarding my medical information, with the following exceptions (check any that apply):I grant NO access to my parents and/or guardians. No medical records, health information, or appointment information can be discussed or released.
(optional) I grant PARTIAL access to my parents and/or guardians regarding my medical information, with the following exceptions (check any that apply):

I do not grant access to information regarding my sexual healthI do not grant access to information regarding my mental healthI do not grant access to information regarding my substance use history
If you are granting access to your parents and/or guardians please fill out the following:
Name of Parent/Guardian
Relationship to you
Name of Parent/Guardian
Relationship to you
This consent is valid from the date signed. I understand that I can withdraw or change this consent at any time in writing.
Patient Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

HIPAA Consent and Medical Release Form