Free HIPAA Medical Release Form

Please complete this form to authorize the release of your medical information.
Name
Contact Number
Purpose of Release
Personal Use
Legal Use
Insurance Claims
Coordination of Care
Information to be Released
Entire Medical Record
Treatment Records
Billing and Payment Information
Acknowledgement and Signature
By signing below, I acknowledge and agree that I have been informed of my rights under HIPAA and understand that this release allows my PHI to be disclosed as specified above. I understand that once disclosed, my PHI may no longer be protected under HIPAA if the recipient is not a covered entity. I am signing this form voluntarily, and it is not a condition for receiving treatment or services.
Name:
Date:
Thank you for your submission!
We appreciate you taking the time to submit.
Create free forms at Template.net
- 100% Customizable, free editor
- Access 1 Million+ Templates, photo’s & graphics
- Download or share as a template
- Click and replace photos, graphics, text, backgrounds
- Resize, crop, AI write & more
- Access advanced editor
Facilitate authorized medical information sharing with the HIPAA Medical Release Form Template from Template.net. This editable and customizable template allows patients to specify what medical information can be released and to whom. Personalize it with our AI Editor Tool to suit your organization's procedures. Its layout supports informed consent and compliance with HIPAA standards.