HIPAA Compliance & Records Release Authorization Form
This document provides a sample authorization for use or disclosure of protected health information and specifies your rights under the Health Insurance Portability and Accountability Act of 1996. This form also serves as an authorization to release records from past providers. Please work directly with your legal council or Human Resources professional to ensure your office is legally compliant while using any records release form.
AUTHORIZATION FOR USE OR DISCLOSURE OF
PROTECTED HEALTH INFORMATION
(Page 1 of 2)
1. Client’s name:__________________________
2. Date of Birth: ____/___/___ 3. SSN: ____-____-_____
4. Date authorization initiated: ___/___/___
5. Authorization initiated by:____________________________________
Name (client or provider) (If provider, please specify relationship to client)
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