HIPAA Release

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Authorization *

I authorize the release of information including the diagnosis, records; examination rendered to me and claims information. This release will remain in effect until terminated by me in writing.

This information may be released to:

Spouse

Child(ren)

Other

Information is not to be released to anyone

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

I prefer: *

Voice Call

Text Message

If you are unable to reach me: *

You may leave a detailed message.

You may leave a message asking me to return your call.

Signature *

By signing, I certify that the above information is correct to the best of my knowledge, and I have read and understand Apotheworx's HIPAA privacy policy.

First Name

Last Name

Date *

MM

DD

YYYY