• YOUR COMPANY NAME

    Authorization for Use and Disclosure of Protected Health Information

    Note: It is office policy of Fictitious Dallas Medical Center not to release confidential medical information regarding your treatment to family members or friends except for:

    1. Parent/legal guardian of minor
    2. Other person authorized by patient (listed below)
    3. Emergency situations
    4. Other as permitted by Health Insurance Portability and Accountability Act of 1996 (HIPAA)

  • Patient DOB*
     - -
    2 digit month, 2 digit day, 4 digit year
  • I authorize Fictitious Dallas Medical Center to disclose my medical information to:
    Rows

  • This form provides authorization to Fictitious Dallas Medical Center to use or disclose certain contents of your personal health information to those listed above.

    I have received and read a copy of the Notice of Privacy Practices for Fictitious Dallas Medical Center. I hereby authorize the use or disclosure of my health information as described. (If you need another copy please request one at the front desk.)

  • Date of Signature*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: