HIPAA Authorization for Electronic Health Information Exchange

Patient Information

Full Name

Date of Birth

Address

Phone Number

Recipient of Information

Name of Person/Organization Contact Information

Purpose of Disclosure

Information to be Disclosed

Expiration

This authorization expires on (date or event):

Additional Information

Authorization & Acknowledgement

I hereby authorize the electronic exchange of my health information according to the details above. I understand that I may revoke this authorization at any time unless action has already been taken based on this authorization.

Signature of Patient or Legal Representative

Date

If signed by a legal representative:

Relationship to Patient