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.

          • Medical Records

          • Billing Records

          • Laboratory Results

          • Diagnostic Reports

          Purpose of Release

            • Continuity of Care

            • Legal Purposes

            • Personal Use

            • 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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