Authorization to Release Patient Information
Developed by lawyers to meet HIPAA requirements, this one-page form obtains a patient’s written authorization to release protected health information, with ample writing space to clearly indicate:
• Provider name and address
• Patient name and identification information
• Date of healthcare service(s) covered by release
• Purpose of release
• Type of records that may be released
• Acknowledgment of release of AIDS/HIV, psychiatric, or substance abuse information
• Confirmation of compensation to be received (if applicable)
• Expiration date
• Provider name and address
• Patient name and identification information
• Date of healthcare service(s) covered by release
• Purpose of release
• Type of records that may be released
• Acknowledgment of release of AIDS/HIV, psychiatric, or substance abuse information
• Confirmation of compensation to be received (if applicable)
• Expiration date
- Size: 8 1/2" x 11"
- Paper: white paper, printed one side, black ink
- Punching: 5-hole punched top and side
- Packaging: 100 per pad