Authorization to Release Patient Info 2-Part Form

Reviewed and in compliance with the HIPAA Mega Rule! Developed by lawyers to meet HIPAA requirements, this two-part 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.

The second copy my be sent to the receiving facility / provider, or given to the patient for his or her records.

Also available as a 1-part form (Stock No. 1773).

Briggs offers a complete line of HIPAA documentation. Also see:
Notice of Privacy Practices / Acknowledgment of Receipt - Updated!(Stock No. 1770)
Business Associate Agreement - Updated! (Stock No. 1771)
Request to Review or Obtain Copies of Protected Information (Stock No. 1772)
Request for Amendment of Information (Stock No. 1775)
Denial of Amendment (Stock No. 1776)
Disclosure Log - Updated!(Stock No. 1779)
Confidential Patient Sign-In Log (Stock No. 1791)

8 1/2" x 11" (detached), 2-part carbonless snap-set, white paper, black ink, 5-holes punched top and side, wrapped in 100s.