How to Prepare HIPAA Release Form?

If you want to get information about your treatment, ask your healthcare provider med help lakeshore to give a fillable form to complete. Whether you need information about your medication, payment or billing for services, complete the HIPAA Release Form. It is required to include the following:

• your personal data: name, last 4 of SSN or employee ID, date of birth;
  
• type of data to be disclosed;
  
• name of the medical establishment;
  
• name of an individual, which can get access to the information mentioned above;
  
• your signature and the date of completing the document.
  

from Medical Release Form https://medicalreleaseform.tumblr.com/post/168004445236
via Medical release form
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