HIPAA Privacy Authorization Form Please complete the information below and submit the form online. This form contains confidential information and is delivered to your doctor through a secure Internet connection.Patient Name* First Last Date of Birth* MM slash DD slash YYYY I hereby authorize all medical service sources and health care providers to use and/or disclose the protected health information (‘‘PHI’’) I authorize the disclosure of information regarding my billing, condition, treatment, and prognosis to the following individual(s):Disclosure authorized toClick the plus sign to add additional individuals.NameRelationship This medical information may be used by the persons I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.Signature*Date* MM slash DD slash YYYY Δ
