HIPAA Authorization Form
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Date today
-
Month
-
Day
Year
Date
age
Date From
*
-
Month
-
Day
Year
Date
Date To
*
-
Month
-
Day
Year
Date
Allowed Purpose of Disclosure of Information
*
Indicate the purpose of disclosure (e.g. For research, for sponsorships, further development of study)
Person Allowed to Disclose Information
*
Prefix
First Name
Last Name
Suffix
Type of Medical Information to be disclosed
*
All Medical Records
Ambulatory Clinic Records
Medical Consultations
Dental Records
Discharge Records
Emergency Records
Financial Records
Medical History & Physical Exams
Imaging Reports
Laboratory & Pathology Reports
Operation Reports
Progress Notes
Psychological Tests
Other
Other Information allowed to be disclosed
*
I give consent to the release of my HIV/AIDS testing information if there is any
I give consent to the release of information pertaining to drugs and alcohol
I give consent to the release of my genetic information and family background information
I give consent to the release of information pertaining to mental health diagnosis or treatment.
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Signature of Patient / Subject
*
Date Signed
*
-
Month
-
Day
Year
Date
Submit
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Parent or Legally Authorized Representative
In case the subject is beyond the legal age of consent:
Name of Parent or Guardian
First Name
Last Name
Relationship to Subject
Signature of Parent / Guardian
Date Signed
-
Month
-
Day
Year
Date
Submit
Should be Empty: