Free HIPAA Authorization to Disclose Form Template
HIPAA Authorization to Disclose Form
Please complete this form to give authorization to disclose your information.
Name
Date of Birth
Email Address
Information to Be Disclosed
Check all that apply
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Complete Medical Record
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Medical History and Physical Exam
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Lab Results
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Billing Information
Purpose of Disclosure
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Continuity of Care
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Legal Purposes
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Insurance
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Personal Use
Acknowledgment and Consent
By signing below, I acknowledge that I understand this authorization is voluntary and can be revoked at any time by providing written notice to the company. The information disclosed may be subject to re-disclosure by the recipient and may no longer be protected under HIPAA.
Name:
Date:
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