HIPAA-Authorization to Release Information:
Protected health information may be disclosed without written authorization only in the purposes specifically outlined in the Notice of Privacy Practice. All other uses and disclosures require this form which the patient fills out for authorization.
Format:
8.5" x 11", 2 Part NCR with black ink- Blue "Void" security background. 5 hole punch left and 2 top for insertion in charts. Packaged in 100's
