Authorization for Release of Protected Health Information Form

Captures a patient's signed consent to release their protected health information to a specific third party.

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Date

Name of Patient

First Name

Last Name

Name of Releasee / Personal Information Controller

Address

Street Address

City

State / Province

ZIP / Postal Code

Phone Number

Email

Authorization

Consent to Release of Health Information:

Yes No

Health Information

This Authorization Expires on the Following Date or Event:

Date or Event

I Understand I May Revoke This Authorization at Any Time.

Name of Patient/Representative

First Name

Last Name

Signature

Sign here

Date Signed

Relation to Patient (if Releasor Is Not the Patient)

Upload Proof of Identity

Max 10 MB per file

Type of Identification

Identification Number

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