Authorization to Disclose Health Information

Your health and medical information is considered sensitive and private and is afforded protection under the law. However, there are circumstances when you may want to provide this information to another individual or entity (e.g. insurance companies, employers, etc.).

This form of Authorization to Disclose Health Information allows you the flexibility to determine what types of information are to be released and under what circumstances. In addition, this form complies with the HIPAA (Health Insurance Portability and Accountability Act) Privacy Rules.This form does not allow for the release of mental health information

This form can be used in all states.

This package contains (1) Instructions and Checklist for the Authorization to Disclose Health Information (the “Authorization”); (2) Information regarding the Authorization; and (3) the Authorization.

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• Includes:

  
  √ Instructions
  √ Free Checklist

• State:

   All

• Number of Pages:

   4

• File Types Included:

  
  √ Microsoft Word
  √ Adobe PDF
  √ WordPerfect
  √ Rich Text Format

• Compatible with:

  Windows and Mac OS