HIPAA Release Form Template
- Patient Name
First NameMiddle NameLast Name
- Date of Birth
- Healthcare Provider Name or Person who shall obtain information
- Address of Recipient
- What Information shall be disclosed (please indicate the specific information if selecting 'other')
All Medical InformationMental Health InformationDrug and Alcohol Abuse Treatment RecordsInformation on Communicable DiseasesCongenital Information and DiseasesGenetic RecordsCommunicable Diseases, including AIDS and HIV
Period of Effectivity
- Effective Period From
- Effective Period Until
- All Past, Present, and Future Periods?
All Past, Present, and Future Periods
- From Signing of this Agreement Until:
- Method of Disclosure
Softcopy document (electronic document or web)Hardcopy document
- Purpose of disclosure
Please indicate "at my request" if you wish not to enumerate the details
I understand that the information I am disclosing to individuals or organizations above may not be protected by the State or Federal rules governing privacy and security of data.
I hereby understand that I may revoke the authorization I have provided in sharing my health information at anytime upon submitting a notice in writing to the healthcare provider and/or the specified persons indicated above.
I fully understand that in case my information has been shared prior revocation, the knowledge acquired by the recipients cannot be revoked.
I understand that my failure to sign or the cancellation of this authorization does not avoid from receiving treatment, enrollment, or eligibility for or benefits I am entitled to receive, provided the information herein shall not be required in determining whether I am eligible to receive treatments or benefits or to pay for the services I receive.
- Signature of Patient or Representative
- Name of Patient or Representative
First NameLast Name
- Date Signed