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無料 HIPAA 医療記録開示同意書

HIPAA 準拠の医療記録開示同意書を 2 分で作成 — 入力して印刷または PDF 保存、署名して送付。

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