Form Hipaa-12 - Authorization Form For Release Of Health Information printable pdf download

Form Hipaa-12 - Authorization Form For Release Of Health Information

AUTHORIZATION FORM FOR RELEASE OF HEALTH INFORMATION

PATIENT NAME: ____________________________________________________________________

LAST

FIRST

MAIDEN/OTHER NAME

DATE OF BIRTH: _______-_______-________

SS#:_________-________-_________

DAY

MEDICAL RECORD #: _____________________________________________________

ADDRESS: ______________________________________________________________

CITY: ____________________________

STATE: ___________

ZIP: ___________

DAY PHONE: __________________

EVENING PHONE: ___________________

I HEREBY AUTHORIZE:

NAME OF PHYSICIAN, HOSPITAL, MEDICAL GROUP, COMPANY:

_______________________________________________________________________

ADDRESS: ______________________________________________________________

CITY: ____________________________

STATE: ___________

ZIP: ___________

PHONE: __________________________

FAX: ______________________________

TO RELEASE MY HEALTH INFORMATION TO PLANNED PARENTHOOD:

HEALTH CENTER ADDRESS: _________________________________________________

CITY: ____________________________

STATE: ___________

ZIP: ___________

PHONE: __________________________

FAX: ______________________________

_______________________________________________________________________

PLANNED PARENTHOOD TO RELEASE MY HEALTH INFORMATION TO A THIRD PARTY

NAME OF RECEIPENT_______________________________________________

ADDRESS: _________________________________________________________

CITY: ____________________________STATE: ___________ZIP: _____________

PHONE: __________________________ FAX: ____________________________

HEALTH INFORMATION TO BE RELEASED:

I specifically authorize release or receipt of the following information:

DATES



Medical history

____________________



Physical exam

____________________



Progress notes related to: ____________________

____________________



Substance abuse (including alcohol/drug abuse)

____________________



Lab reports related to: ________________________

____________________



Mental health

____________________



X-ray reports related to: ______________________

____________________



HIV related information (not including test results

_______

HIPAA-12 (9/1/16)

Form Hipaa-12 - Authorization Form For Release Of Health Information

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