HIPPA Release Form

Patient Name*

First Name

Last Name

Date of Birth*

The Patient identified above hereby authorizes New Smyrna Wellness Center to release and disclose Patient’s Protected Health Information as defined by HIPAA (“PHI”) to the following person or organization (“Recipient”):

Recipient Name

Relationship to Patient

This Authorization applies to the following PHI:*

All Records pertaining to: Other

Name

Other Name

This disclosure of PHI will not include the following information unless the appropriate box is checked:*

Any records of treatment for drug and/or alcohol dependency or abuse. Any record of mental health treatment, psychological services, social services, including communications made to a social worker or psychologist. Any record of testing, care, treatment or research pertaining to HIV, AIDS or other communicable diseases.