HIPPA Release Form AUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTHCARE INFORMATION From time to time we may need to communicate with the doctors or health insurance companies who provided care to you for your injuries. Please fill in the fields below to authorize our firm to communicate with your doctors and insurance company regarding your medical bills and records. You may request a copy of your completed forms from our office at any time.PATIENT NAME:(Required) MAIDEN NAME: ADDRESS:(Required) DATE OF BIRTH:(Required) MM slash DD slash YYYY SSN:(Required) PHONE:(Required)PLEASE SIGN YOUR HEALTH AUTHORIZATION FORM:(Required)Date(Required) MM slash DD slash YYYY Δ
