Patient Information Release Form (HIPAA Release Form)
Please correct the errors described below.
Date of Birth:
Release of Information
I authorize the release of information including the diagnosis, records, examination, treatment, payment and Health Care operations. I authorize this information to be disclosed in the following ways: written/photocopy/paper; electronic format; verbal; fax; patient portal
This information may be released to:
If you selected Other, please specify:
Information is not to be released to anyone.
My cell number
If unable to reach me:
You may leave a detailed message on my voicemail
Please leave a message asking me to return your call
Other, please specify:
The best time to reach me is (day):
Your message will be encrypted.
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