Required Field

Please complete all sections of this HIPAA release form. If any sections are left blank, this form will be invalid, and it will not be possible for your health information to be shared as requested.

Personal Info

First Name

Last Name

Section I

1. I authorize the following person(s) and/or organization(s) to disclose my PHI as specified below:

Name(s) (Doctor, Coach, Trainer, etc.):

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Organization(s) (Company of above):

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Address (Contact Location):

Characters: 0/255

2. I authorize the following person(s) and/or organization(s) to receive my PHI as disclosed by the person(s) and/or organization(s) above.

(Insert Clinic Name Here)

3. Protected Health Information I authorize for disclosure:

Complete health record (including records relating to diagnoses, lab test results, history/physical notes, narrative reports, billing data, and treatment for all conditions).

Complete health record except for the following information:

Mental health records

Communicable diseases (including, but not limited to, HIV and AIDS)

Alcohol/drug abuse treatment records

Genetic information

Other (Specify)

Section II

1. Authorization for release of PHI covering the period of health care:

From:

To:

All past, present, and future periods.

2. This authorization will remain in effect:

For exactly one year

Until (9) months after my death

From the date of this Authorization until the:

Section Ill

1. I understand that I am permitted to revoke this authorization to share my health data at any time and can do so by submitting a request in writing to:

(Insert Clinic Name)

2. I understand that: (please check each box)

In the event that my information has already been shared by the time my authorization is revoked, it may be too late to cancel permission to share my health data.

I understand that I do not need to give any further permission for the information detailed in Section II to be shared with the person(s) or organization(s) listed in section III.

I understand that the failure to sign/submit this authorization or the cancellation of this authorization will not prevent me from receiving any treatment or benefits.

And, I am entitled to receive, provided this information is not required to determine if I am eligible to receive those treatments or benefits.

Section lV (Patient or legal representative)

Name of Patient or Legal Representative):

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Relationship to patient:

Characters: 0/255

Date:

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