Generic Authorization Medical Release FormGeneric Authorization Medical Release FormGeneric Authorization Medical Release Form
Download the document to the computer for easy use
There are more pages to preview,Read on

HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF PATIENT
INFORMATION PURSUANT TO 45 CFR 164.508

TO:

______________________________________________________________________
Name of Healthcare Provider/Physician/Facility/Medicare Contractor
______________________________________________________________________
Street Address
______________________________________________________________________
City, State and Zip Code

RE:

Patient Name: _________________________________________________________
Date of Birth: _________________ Social Security Number: ____________________

I authorize and request the disclosure of all protected information for the purpose of review
and evaluation in connection with a legal claim. I expressly request that the designated record
custodian of all covered entities under HIPAA identified above disclose full and complete protected
medical information including the following:
All medical records, meaning every page in my record, including but not limited to: of