Free HIPAA Authorization Form Template
HIPAA Authorization Form
Please complete this form to authorize the use of your Protected Health Information.
Date
Name
Phone Number
Information to be Released
-
Medical Records
-
Test Results
-
Billing Information
Purpose of Disclosure
-
Personal Use
-
Insurance Claims
-
Legal Purposes
-
Ongoing Care
Acknowledgment
By signing below, I understand I can revoke this authorization anytime by submitting a written request. Revocation won’t apply to actions already taken based on this authorization. Once disclosed, information may not be protected under HIPAA.
Name:
Date:
Thank you for your submission!
We appreciate you taking the time to submit.
Create free forms at Template.net
