[PDF] HIPAA Release Form PDF in English

A HIPAA release form allows you to authorize your doctor to share your specified private health information with designated recipients of your choice, which you can revoke at any time in writing to stop future disclosures.

PDF TitleHIPAA Release Form
File Size60 kb

About PDF

  • A HIPAA release form allows your doctor to share your private health information with someone you choose.
  • You list who can get your information and which details they can access, like test results, treatment records, billing, etc.
  • It explains the information will be used or disclosed at your request to the recipients you authorize.
  • The form states you can revoke the release at any time to stop future sharing. Your revocation must also be in writing.
  • By signing, you allow your health information to be released as specified. The release expires per the date you provide.

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