HIPAA Release

1

Packet

new1

new2

new3

new4

male2

male3

2

Patient Information* This field is required.

First Name

Last Name

Date of Birth

3

Receivers of Medical InformationPlease list the NAME, RELATIONSHIP, and PHONE of all individuals or organizations who may need to speak with any of our staff regarding, but not limited to, your medical information such as coordination of care, billing, insurance and scheduling.

4

Information to Release* This field is required.

I hereby authorize the release of my complete health record (including records relating to mental health care, communicable diseases, HIV or AIDS, and treatment of alcohol/drug abuse).

I hereby authorize the release of my complete health record with the exception of the items listed on the following page.

5

List any Specific Instruction or Limitation

6

Terms of Release* This field is required.Please review all terms before selecting the box.

7

Authorized Person* This field is required.

Patient

Parent

Legal Guardian

Other

8

Authorized Person Information* This field is required.

First Name

Last Name

Date of Birth

9

Authorized Person Signature* This field is required.