HIPAA Waiver Form

HIPAA Waiver Form
Date
MonthDayYear
Date
Name of Patient
First NameLast Name
Date of Birth
MonthDayYear
Date
Age
Type of Health Records to be Disclosed
Other
Period of Allowed Heath Records Disclosure
Date From
MonthDayYear
Date
Date To
MonthDayYear
Date
Purpose of Authorization
This Authorization Expires
By signing this form, I understand and acknowledge that I may revoke this waiver at any time in writing. However, in cases where disclosures were already been made prior to revocation, I understand that such revocations may not be taken back.
Under the HIPAA Privacy Standards, I understand that parties who are not a party to this agreement may possibly redisclose the information.
I understand that this disclosure is not mandatory and I may choose not to sign this waiver. I understand this waiver may not be conditioned upon a treatment.
I understand that upon submission of this waiver, I will receive a copy. The copy that I receive shall be deemed an original.
Signature of Patient
Clear
Patient is unable to sign
Reason
Please explain why patient is unable to sign this waiver
Name of Parent/Guardian/Representative
First NameLast Name
Signature of Parent/Guardian/Representative
Clear
Should be Empty: