HIPAA Authorization Form
Permission to Disclose Health Information
Name
First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Date today
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Month
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Day
Year
Date
age
Date From
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Month
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Day
Year
Date
Date To
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Month
-
Day
Year
Date
Allowed Purpose of Disclosure of Information
Indicate the purpose of disclosure (e.g. treatment plans, visits)
Person Allowed to Disclose Information
Prefix
First Name
Last Name
Person Allowed to Disclose Information
Prefix
First Name
Last Name
Type of Medical Information to be disclosed
All Medical Records
Medical Consultations
Discharge Records
Emergency Records
Medical History & Physical Exams
Imaging Reports
Laboratory & Pathology Reports
Progress Notes
Medications
Treatments
Other
Other Information allowed to be disclosed
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.
I give consent to discuss above SELECTED in medical information to be disclosed
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Signature of Patient / Subject
Date Signed
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Month
-
Day
Year
Date
Back
Continue
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Legally Authorized Representative
Relationship to Subject
SELF
Signature of Patient
Date Signed
-
Month
-
Day
Year
Date
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Should be Empty: