HIPAA Release Form
Medical Information Release Form

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FPA is unable to discuss your treatment with anyone unless you give us written permission.
Multiple Choice
Health Information to be disclosed upon the request of the person named above -- (Check either A or B):
  • Mental health records
  • Communicable diseases (including HIV and AIDS)
  • Alcohol/drug abuse treatment.
This authorization shall be effective until terminated by me. (NOTE: You may revoke this authorization in writing at any time by notifying your health care providers, preferably in writing.)
Electronically SIgned
I, the undersigned, acknowledge and agree that by typing my name, clicking “I Accept,” or by other electronic means, I am signing this document electronically.
Date / Time