Medical Information Release Form
HIPAA RELEASE FORM
Patient's Name
*
First Name
Last Name
Patient's DOB
*
-
Month
-
Day
Year
Release of Information
*
I authorize the release of information including the diagnosis, records; examination rendered to me and claims information.
My medical information is not to be released to anyone other than myself.
If authorization is given, this information may be released to:
Name
Relationship
Phone Number
Format: (000) 000-0000.
If the clinic is unable to reach me:
*
You may leave a detailed message with medically sensitive information on my voicemail.
Please leave a message asking me to return your call. I do not consent to my personal medical information to be left on a voicemail.
The best time of the day to reach me is:
*
Morning (9AM-11AM)
Afternoon (12PM-3PM)
Early Evening (4PM-5PM)
Anytime
The best day of the week to reach me is:
*
Monday
Tuesday
Wednesday
Thursday
Friday
Anyday
*This release of information will remain in effect until terminated by me in writing.*
Patient's Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: