Medical Information Release

HIPAA Release Form

First Name *

Last Name *

Phone *

Email *

Date of Birth *

Release of Information

I authorize the release of information including the diagnosis, records; examination rendered to me and claims information. This information may be released to: *

Spouse

Children

Information is not to be released to anyone

Other

If Other is selected, please mention who:

This Release of Information will remain in effect until terminated by me in writing.

Messages

Please call:

My home

My work

My cell

If unable to reach me: *

You may leave a detailed message

Please leave a message asking me to return your call

Other

If Other is selected, please specify how:

The best time to reach me is: *

Signature *

Clear

Date *