Authorization to Release Information 📄

HIPPA AUTHORIZATION FORM
Authorization to Release Information

Use this form to authorize the release of specific information for administrative purposes.
Deceased Individual’s Full Name*

First NameLast Name
Deceased Individual’s Date of Birth*

MonthDayYear
Date
Deceased Individual’s Date of Death*

MonthDayYear
Date
Authorized Representative/Client’s Full Name*

First NameLast Name
Relationship to Deceased*
Authorization

I authorize Final Affairs Concierge to contact healthcare providers, pharmacies, and medical suppliers and to disclose or receive only the limited information necessary to notify providers of death, cancel services and prescriptions, and confirm account closure. The information covered by this authorization includes appointment status, prescription status, and service enrollment. This authorization does not include release of full medical records.

Purpose:

This authorization is for the purpose of facilitating administrative closure of services after death.

Expiration:

This authorization will expire 90 days from the date of signature unless revoked earlier.

Right to Revoke:

I understand that I may revoke this authorization at any time in writing.

Acknowledgement:

I understand and authorize the release of this information as described
Client Name (Printed)*
Signature of Authorized Representative/Client*
Date of Signature*

MonthDayYear
Date
Should be Empty: