Medical Information Release Form
(HIPAA Release Form)
Name: Date of Birth: //
Release of Information
I authorize the release of information including the diagnosis, records;
examination rendered to me and claims information. This information may be released to:
Information is not to be released to anyone.
This Release of Information will remain in effect until terminated by me in writing.
Please call my home my work my cell Number:
If unable to reach me:
you may leave a detailed message
please leave a message asking me to return your call
The best time to reach me is (day) between (time)
Signed: Date: //
Witness: Date: //
Powered By Lettercrank.com