HIPAA Authorization - Patient Consent Form

HIPAA Release of Information Authorization Form
I give my permission for Dimer Health to disclose my complete health record including, but not limited to, diagnoses, diagnostic results, treatment, and billing records for all conditions with the person(s) or organization(s) I have specified below.
Name or Organization:
Relation to patient:
I understand that the person(s)/organization(s) listed above may not be covered by state/federal rules governing privacy and security.
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Name of Legal Representative (If other than Patient)

First NameLast Name
Relationship to Patient
I have carefully read and fully understand this informed consent form and have had all my questions answered.
Date*

MonthDayYear
Date
Signature*

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Athena ID
Should be Empty:

HIPAA Release of Information Authorization Form