HIPAA Privacy Form
(HIPAA)
Patient's Legal Name
*
Patient Birth Date
*
-
Month
-
Day
Year
Date
Patient Home Phone
-
Area Code
Phone Number
Patient Cell Phone
*
-
Area Code
Phone Number
Patient Work Phone
-
Area Code
Phone Number
Patient Email
*
example@example.com
Messages: Please Call
*
My Home
My Work
My Cell
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
Evening
The best time to reach me is:
Relationship to patient
*
Self
Parent
HIPAA/Medical Information Release
I authorize the release of information including the diagnosis, records, examination rendered to me and insurance claims information. This information may be released to:
*
Parent(s)
Spouse/Significant Other
Child(ren)
Information is not to be released to anyone
Please list the names from above:
Signature
Person filling out this form:
*
Relationship to patient:
*
Signature
*
Clear
Witness (If Applicable)
Date:
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: