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HIPAA Authorization for Release of Health Information
Authorization permitting designated individuals to access your protected health information under the Health Insurance Portability and Accountability Act.
PDF TemplateUse the instructions below to complete this form
Instructions
Name the individuals authorized to receive your health information. Specify the scope of information that may be disclosed (all records, specific conditions, mental health, substance abuse treatment). This is separate from and supplements your healthcare directive. The authorization can be broad or limited. You may revoke it at any time in writing. Sign and date. Provide copies to your healthcare providers and authorized individuals.