harteyecare.net - Medical Information Release Form

Medical Information Release Form

HIPAA Release Form
Name:
Date of Birth:

MonthDayYear
Date
Release of Information
I authorize the release of information including the diagnosis, records; examination rendered to me and claims information.Information is not to be released to anyone.
This information may be released to:

SpouseChild(ren)Other
Spouse Name
Child(ren) Name
This Release of Information will remain in effect until terminated by me in writing.
Messages
Please call

my homemy workmy cell number
Your cell number
Please enter a valid phone number.
If unable to reach me:

you may leave a detailed messageplease leave a message asking me to return your call
The best time to reach me is (day) Day between (time) Time
Signature

Clear
Date

MonthDayYear
Date
Witness
Date

MonthDayYear
Date
Should be Empty:

Medical Information Release Form