"Hipaa Disclosure Form"

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HIPAA Disclosure Form
Hospital:
Doctor:
Patient Name:
Date:
Listed Address:
Preferred Correspondence Address:
Listed Phone No.
Preferred Phone No.
Listed Email Address:
Preferred Email Address:
Would you like our correspondence with you to be marked “Confidential”? q Yes
q No
May we identify ourselves over the phone? q Yes q No
May we leave messages? q Yes q No
I, the Patient, hereby authorize the doctor and/or hospital listed above to release my medical information
(appointments, lab/x-ray results, diagnoses, treatments, medications, surgeries, etc.) via postal mail, telephone,
fax, or email to the following family members:
Name:
DOB:
Relationship:
Name:
DOB:
Relationship:
Name:
DOB:
Relationship:
Name:
DOB:
Relationship:
Name:
DOB:
Relationship:
I further release my medical information to the following physicians, clinics, and/or hospitals:
Doctor:
Clinic:
Phone:
Doctor:
Clinic:
Phone:
Doctor:
Clinic:
Phone:
Doctor:
Clinic:
Phone:
Doctor:
Clinic:
Phone:
www.FreePrintableMedicalForms.com
HIPAA Disclosure Form
Hospital:
Doctor:
Patient Name:
Date:
Listed Address:
Preferred Correspondence Address:
Listed Phone No.
Preferred Phone No.
Listed Email Address:
Preferred Email Address:
Would you like our correspondence with you to be marked “Confidential”? q Yes
q No
May we identify ourselves over the phone? q Yes q No
May we leave messages? q Yes q No
I, the Patient, hereby authorize the doctor and/or hospital listed above to release my medical information
(appointments, lab/x-ray results, diagnoses, treatments, medications, surgeries, etc.) via postal mail, telephone,
fax, or email to the following family members:
Name:
DOB:
Relationship:
Name:
DOB:
Relationship:
Name:
DOB:
Relationship:
Name:
DOB:
Relationship:
Name:
DOB:
Relationship:
I further release my medical information to the following physicians, clinics, and/or hospitals:
Doctor:
Clinic:
Phone:
Doctor:
Clinic:
Phone:
Doctor:
Clinic:
Phone:
Doctor:
Clinic:
Phone:
Doctor:
Clinic:
Phone:
www.FreePrintableMedicalForms.com