HIPPA Authorization Form Patient's Printed Name First Patient's Email* Patient's Date Of Birth MM slash DD slash YYYY Contact Phone NumberPlease specify the name of person you authorize to use/disclosure of health information about yourself* Please SelectI hereby authorize the medical professionals in receipt of this authorization to disclose records obtained in the course of my evaluation and/or treatment to the class of person presenting this release to you as detailed below via Personal Couriers Facsimile Mail Class of Persons To Whom Protected Health Care Information May be ReleasedHiddenDate MM slash DD slash YYYY Signature of Patient/Legal Guardian or Representative Reset signature Signature locked. Reset to sign again (Relationship, if not signed by patient) HiddenHow do you want the contract to be generated? Send the contract to the client via email Generate the contract to be signed right now
