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Formulaire d'Autorisation HIPAA — Gratuit

Créez une autorisation de divulgation de dossiers médicaux conforme HIPAA en deux minutes — remplissez, imprimez ou enregistrez en PDF, signez et envoyez.

Patient full nameDate of birthProvider / facility releasing recordsPerson/organization authorized to receiveInformation to be releasedPurposeAuthorization expiresDate signed

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HIPAA RELEASE FORM

I, ________________ (DOB: ________________), authorize ________________ to disclose my protected health information as described below to ________________.

Information to be released: ________________. Purpose of disclosure: ________________.

This authorization expires: ________________. I understand I may revoke this authorization at any time by notifying ________________ in writing, except to the extent action has already been taken in reliance on it.

I understand that information disclosed under this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations (45 CFR §164.508). Treatment, payment, enrollment, or eligibility for benefits may not be conditioned on signing this authorization.

Patient / legal representative signature

Date