HIPAA

HIPAA

Health Insurance Portability and Accountability Act

DESIGNATED INDIVIDUALS AUTHORIZATION FORM

I hereby authorize one or all of the designed parties below to request and receive the release of any protected information regarding my treatment, payment, account, or administrative operations related to treatment and payment. I understand the identity of designed parties must be verified before the release of any information.

Name: blanks
Relationship:blank
Phone # :

Name: blanks
Relationship: blank
Phone # : Type a label

Name blanks
Relationship: blank
Phone # : Type a label

Name: blanks
Relationship: blank
Phone # :Type a label

Patient Name (Please Print)*

Patient Signature*

Clear

Date*

Date