Free HIPAA Waiver Form Template
HIPAA Waiver Form
Please read carefully and complete all sections.
Name
Date of Birth
Contact Number
Waiver of HIPAA Rights
I understand that by signing this form, I am waiving certain HIPAA protections for my PHI. I authorize the company to disclose my PHI to the following individuals or entities:
Recipient Name
Relationship to Patient
Company Name
Contact Number
Purpose of Disclosure
-
Personal Use
-
Coordination of Care
-
Insurance or Billing Purposes
-
Legal Purposes
Acknowledgment
By signing below, I acknowledge that I have been informed of my rights under HIPAA and understand that this waiver means certain protections for my PHI are relinquished. I can revoke this waiver at any time by submitting a written request to the company, except where disclosures have already been made.
Name:
Date:
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