HIPAA Release System

Fill out the form and Submit

Email A value is required. First Name 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.