Free HIPAA Release Form Template
HIPAA Release Form
Please complete this form to authorize the release of your Protected Health Information.
Name
Date of Birth
Phone Number
Type of Information to Be Released
Check all that apply.
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Medical Records
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Billing Records
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Laboratory Results
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Diagnostic Reports
Purpose of Release
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Continuity of Care
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Legal Purposes
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Personal Use
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Insurance Claims
Acknowledgments
By signing below, I acknowledge that this may revoke this authorization at any time by providing written notice to my healthcare provider. Any information disclosed prior to the revocation may no longer be protected under HIPAA. I have the right to receive a copy of this authorization form upon request.
Name:
Date:
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