AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA Submit HIPAA Authorization Form Patient's Name(Required) First Last Phone(Required)Email(Required) Date of Birth(Required) DD slash MM slash YYYY Scan Copy of HIPPA Authorization Form with Duly Signed(Required)Accepted file types: pdf, Max. file size: 4 MB.CommentsThis field is for validation purposes and should be left unchanged.
