HIPAA Authorization - Patient Consent Form

HIPAA Release of Information Authorization Form
I give my permission for 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