HIPAA LogIn
Signature LogIn
HIPAA Release System
Fill out the form and Submit
First Name
A value is required.
Email
A value is required.
Last Name
A value is required.
UserName
A value is required.
Password
A value is required.
Confirm Password
A value is required.
The values don't match.
Medical Record Number
Invalid format.
A value is required.
Patient's Date of Birth
A value is required.
Social Security Number
A value is required.
Name of Place Releasing
A value is required.
Name of Place Recieving
A value is required.
Information to be Shared
Psychotherapy Notes (if checking this box, no other boxes may be checked)
Entire Medical Record
Billing Information
Mental Health Records
Substance Abuse Records
Other
Select the Information to be Shared
Purpose of Disclosure
Insurance
Continued Treatment
Legal
At my or my representative’s request
Other
Select the Purpose of this release
Policy Holder
A value is required.
Policy Number
A value is required.
Group Number
A value is required.
Eligibility Date
A value is required.