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Compliant HIPAA Authorization Form
Please fill the form below
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*
Full Name:
*
First Name
*
Last Name
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Date of Birth:
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Date format is invalid, please check it again
The value must be greater than or equal to -21474836487
The value must be less than or equal to 2147483647
Age:
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The value allows only numbers
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The value must be greater than or equal to -21474836487
The value must be less than or equal to 2147483647
*
Date From:
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Date format is invalid, please check it again
The value must be greater than or equal to -21474836487
The value must be less than or equal to 2147483647
*
Date To:
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Date format is invalid, please check it again
The value must be greater than or equal to -21474836487
The value must be less than or equal to 2147483647
Allowed Purpose of Disclosure of Information:
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Person Allowed to Disclose Information:
First Name
Last Name
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Type of Medical Information to be disclosed:
All Medical Records
Ambulatory Clinic Records
Medical Consultations
Dental Records
Discharge Records
Emergency Records
Financial Records
Medical History & Physical Exams
Imaging Reports
Laboratory & Pathology Reports
Operation Reports
Progress Notes
Psychological Tests
Others
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Please specify:
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Other Information allowed to be disclosed:
I give consent to the release of my HIV/AIDS testing information if there is any
I give consent to the release of information pertaining to drugs and alcohol
I give consent to the release of my genetic information and family background information
I give consent to the release of information pertaining to mental health diagnosis or treatment
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Signature of Patient / Subject:
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Date Signed:
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Date format is invalid, please check it again
The value must be greater than or equal to -21474836487
The value must be less than or equal to 2147483647
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