Free HIPAA Waiver Form

Please read carefully and complete all sections.
Name
Date of Birth
Contact Number
Waiver of HIPAA Rights
I understand that by signing this form, I am waiving certain HIPAA protections for my PHI. I authorize the company to disclose my PHI to the following individuals or entities:
Recipient Name
Relationship to Patient
Company Name
Contact Number
Purpose of Disclosure
Personal Use
Coordination of Care
Insurance or Billing Purposes
Legal Purposes
Acknowledgment
By signing below, I acknowledge that I have been informed of my rights under HIPAA and understand that this waiver means certain protections for my PHI are relinquished. I can revoke this waiver at any time by submitting a written request to the company, except where disclosures have already been made.
Name:
Date:
Thank you for your submission!
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Grant specific exceptions to HIPAA regulations with the HIPAA Waiver Form Template from Template.net. This fully editable and customizable template simplifies the process of obtaining waivers for specific uses of protected health information. Adapt the form to meet your organization’s requirements using our AI Editor Tool. Its structured format ensures both clarity and compliance.