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  • HIPPA Disclosure List

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    Leah Doherty
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    The document contains a form for listing a patient's doctors and clinics to authorize the disclosure of medical information under HIPAA regulations. It requests the patient's name, date of birth, phone number and then includes fields for the name, city, phone number, fax number and additional notes for three different doctor/clinic entries.

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    The document contains a form for listing a patient's doctors and clinics to authorize the disclosure of medical information under HIPAA regulations. It requests the patient's name, date of birth, phone number and then includes fields for the name, city, phone number, fax number and additional notes for three different doctor/clinic entries.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    8 views2 pages

    HIPPA Disclosure List

    Uploaded by

    Leah Doherty
    The document contains a form for listing a patient's doctors and clinics to authorize the disclosure of medical information under HIPAA regulations. It requests the patient's name, date of birth, phone number and then includes fields for the name, city, phone number, fax number and additional notes for three different doctor/clinic entries.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 2

    HIPAA Disclosure Doctor/Clinic List

    Patient Name: _______________________ D.O.B. __________ Phone:__________________

    Doctor/Clinic Name & City: _____________________________________________________

    Phone Number: _________________________ Fax Number : _________________________

    Notes : ______________________________________________________________________

    ____________________________________________________________________________

    ____________________________________________________________________________

    ____________________________________________________________________________

    Doctor/Clinic Name & City: _____________________________________________________

    Phone Number: _________________________ Fax Number : _________________________

    Notes : ______________________________________________________________________

    ____________________________________________________________________________

    ____________________________________________________________________________

    ____________________________________________________________________________

    Doctor/Clinic Name & City: _____________________________________________________

    Phone Number: _________________________ Fax Number : _________________________

    Notes : ______________________________________________________________________

    ____________________________________________________________________________

    ____________________________________________________________________________

    ____________________________________________________________________________

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