HIPAA Medical Release Form

Your Information

First Name

Middle Name

Last Name

Social Security Number

Phone

Date of Birth:

Month

Day

Year

Who would you like to release your HIPAA medical information to?

First Name

Middle Name

Last Name

Company or Organization (if applicable)

Release

I would like to give the above person, company or organization permission to:

Disclose my complete health record including, but not limited to, diagnoses, lab test results, treatment, and billing records for all conditions.Disclose my complete health record except for the following information (select all that apply):

Mental health recordsCommunicable diseases including, but not limited to, HIV and AIDSAlcohol/drug abuse treatment recordsGenetic informationOther

Please specify other:

Form of disclosure:

Electronic copy or access via web-based portalHard copy

Please detail the reasons why information is being shared. If you are initiating the request for sharing information and do not wish to list the reasons for sharing, write ‘at my request’.

This authorization to share my health information is valid:

From Date:

To Date: