HIPAA Release Form
Medical Information Release Form

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Single Line Text

Date of birth

FPA is unable to discuss your treatment with anyone unless you give us written permission.

Multiple Choice

My Information is NOT to be released to anyone.
I direct my health care and medical services providers and payers to disclose and release my protected health information described below to:

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Health Information to be disclosed upon the request of the person named above -- (Check either A or B):

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A. Disclose my complete health record (including but not limited to diagnoses, lab tests, prognosis, treatment, and billing, for all conditions) and disclose all my...

Mental health records
Communicable diseases (including HIV and AIDS)
Alcohol/drug abuse treatment.

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B. Disclose my health record, as above, BUT do not disclose the following (check as appropriate):

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Mental health records
Communicable diseases (including HIV and AIDS)
Alcohol/drug abuse treatment
Other

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.)

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Print Name of the Individual Giving this Authorization

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Signature

Electronically SIgned

I Agree

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

Date

Time

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HIPAA Release Form Medical Information Release Form

HIPAA Release Form
Medical Information Release Form