Fill and Sign the Permission to Disclose Health Billing Information

PERMISSION TO DISCLOSE HEALTH/BILLING INFORMATION I,       hereby grant permission for       to discuss or release information concerning my medical diagnosis, or information relating to or in my medical records, or any medical information that the aforementioned entity may have on file as it concerns me including but not limited to billing, benefit inquiries, claims, and appeals and complaints, to the following individuals in compliance with required HIPPA guidelines:             Name Relationship to above individual             Name Relationship to above individual             Name Relationship to above individual I understand and acknowledge that signing this authorization is voluntary and that I may refuse to sign it. That my refusal to sign this permission will not affect my ability to obtain treatment, receive payment, or be eligible for benefits. I further understand that I may revoke this authorization at any time by notifying       of my intent to revoke, except to the extent that action has already been taken in reliance on this authorization. State of       ______________________ County I, ______________, a ________________, in and for said county in said state, hereby certify that _____________, whose name is signed to the foregoing conveyance, and who is known to me, acknowledged before me on this day that, being informed of the conveyance, he/she executed the same voluntarily on the same day the same bears date. Given under my hand this the ____ day of ____________, ____. _________________________________ NOTARY PUBLIC Print Name: _______________________ My Commission Expires: ______________________ Copyright 2004 USLegalforms.com