HIPAA Medical Release Form

Please complete this form to authorize the release of your medical information.

Acknowledgement and Signature

By signing below, I acknowledge and agree that I have been informed of my rights under HIPAA and understand that this release allows my PHI to be disclosed as specified above. I understand that once disclosed, my PHI may no longer be protected under HIPAA if the recipient is not a covered entity. I am signing this form voluntarily, and it is not a condition for receiving treatment or services.

Name:

Date:

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