HIPAA Right of Access Form for Family Member/Friend

Please correct the errors described below.

direct my health care and medical services providers and payers to disclose and release my protected health information described below to:

Add new Member/Friend

Health Information to be disclosed upon the request of the person named above (Check either A or B):

unless I revoke it. (NOTE: You may revoke this authorization in writing at any time by notifying your health care providers, preferably in writing.)

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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