Healthcare OCR Consent and HIPAA Authorization Waiver Form
Please complete this form to authorize the scanning, transcription, digitization, and storage of your submitted documents for administrative processing.
Full Name
*
First Name
Last Name
Are you completing this form as the patient or as an authorized representative?
*
Patient
Authorized Representative
If you are an authorized representative, please specify your relationship to the patient
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Description of Documents Submitted
*
Upload Documents for OCR Processing
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Signature of Patient or Authorized Representative
*
Date
*
-
Month
-
Day
Year
Date
Submit Consent
Submit Consent
Should be Empty: