HIPAA Authorization Form

This form authorizes Eileen to access your medical information and communicate with your healthcare providers on your behalf. Your privacy is protected and this authorization may be revoked at any time in writing.

Patient Information

Full Name *

Date of Birth *

Street Address

City

State

ZIP Code

Phone Number *

Healthcare Provider(s) to Contact

List the names of doctors, hospitals, or insurance companies Eileen is authorized to contact on your behalf.

Information Authorized to Share *

Select all types of information Eileen is authorized to access or share on your behalf.

Authorization Valid For *

How long should this authorization remain in effect?

Signature & Date

By typing your full name below, you are electronically signing this HIPAA Authorization Form and confirm that you have read and understand its contents. You understand that you may revoke this authorization at any time by notifying Eileen in writing.

Type Your Full Name as Signature *

Typing your name constitutes a legally binding electronic signature.

Date Signed *

Important: This authorization is voluntary. You have the right to revoke it at any time by contacting Eileen in writing at [email protected]. Revoking this authorization will not affect actions already taken in reliance on it.