Free HIPAA Consent of Release Form Template
HIPAA Consent of Release Form
Complete all sections to authorize the release of your Protected Health Information.
Name
Contact Number
Information to be Released
I authorize the release of the following medical information:
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Complete Medical Record
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Lab Results
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Treatment Notes
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Billing Records
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Imaging Reports
Purpose of Release
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Continuation of Care
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Personal Use
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Legal Proceedings
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Insurance Claim
Acknowledgment and Signature
By signing below, I acknowledge that I am authorizing the release of my PHI as specified. I understand that my information may not be protected by HIPAA once it is disclosed to the authorized recipient.
Name:
Date:
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