Medical Information Release Form (HIPAA Release Form) Name First Last Date of Birth Date Format: MM slash DD slash YYYY Release of Information l authorize the release of information including the diagnosis, records; examination rendered to me, and claims information. This information may be released toSpouseChild(ren) Information is not to be released to anyone. This Release of Information will remain in effect until terminated by me in writing Messages Please callmy homemy workmy cellNumberIf unable to reach meyou may leave a detailed messageplease leave a message asking me to return your callThe best time to reach me is (day).between (time).SignatureDate Date Format: MM slash DD slash YYYY WitnessDate Date Format: MM slash DD slash YYYY
