MyClearStep Medical Release Form
HIPAA AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION. This form is for use when such authorization is required and complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards.
Your name
*
First name
Last name
Your email
*
example@example.com
Date of birth
*
-
Month
-
Day
Year
Date Picker Icon
Social Security Number
*
Enter your 9-digit SSN and do not include dash (-).
Signature
*
This form was created by Shapa Health, Inc.
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