HIPAA Authorization Release Form
Patient Information
Patient Name
Date of Birth
Address
Recipient Information
Individual/Organization to Release Information To
Recipient Address
Information to be Released
Description of Information
Purpose of Disclosure
Purpose
Expiration
This authorization expires on (date or event):
Patient Rights
This authorization is voluntary.
You may revoke this authorization at any time by providing written notice.
Refusal to sign this form will not affect your ability to obtain treatment.
Signature of Patient/Representative
Date
If signed by Representative, describe relationship to patient