Release of Information Form

HIPAA Release Form

Please complete all sections of this HIPAA release form. If any sections are left blank, this form will be invalid and it will not be possible for your health information to be shared as requested.
Section I - Requestor Information
Name of Person Requesting*

First NameLast Name
Date of Birth of Person Requesting*

MonthDayYear
Date
Phone Number of Person Requesting*

Area CodePhone Number
Email Address of Person Requesting*
example@example.com
Address of Person Requesting*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I, {nameOf}, give my permission for Success Care to share the information listed in Section II of this document with the person(s), or organizations I have specified in Section III of this document.
Section II - Health Information
I would like to give Success Care permission to:

Disclose my complete health record including, but not limited to, diagnosis, lab test results, treatment, and billing records for all conditions.Disclose my complete health record except for the following information:
Select the following information to disclose, select all that apply:

Mental health recordsCommunicable diseases including, but not limited to, HIV and AIDSAlcohol/drug abuse treatment recordsGenetic informationOther
Form of Disclosure

Electronic copy accessed via secure web-based portalHard copy - Note: Hard copies will be provided at a cost of $.50 per page
Section III - Who Can Receive My Health Information
I, {nameOf}, give authorization for the health information detailed in section II of this document to be shared with the following entities:

MyselfMy Provider
Provider Name*
Provider Phone*

Area CodePhone Number
Provider Email Address (Leave Blank if Unknown)
example@example.com
Provider Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Section IV - Acknowledgements
Please acknowledge the following by selecting the check box next to each.*

I understand that the person(s)/organization(s) listed above may not be covered by state/federal rules governing privacy and security of data and may be permitted to further share the information that is provided to them.I understand that I am permitted to revoke this authorization to share my health data at anytime and can do so by submitting a request in writing to: Nomi Health D.B.A Success Care 898 N 1200 W Ste 201, Orem, Utah, 84057I understand that in the event that my information has already been shared by the time my authorization is revoked, it may be too late to cancel permission to share my health data.I understand that I do not need to give any further permission for the information detailed in Section II to be shared with the person(s) or organization(s) listed in section III.I understand that the failure to sign/submit this authorization or the cancellation of this authorization will not prevent me from receiving any treatment or benefits I am entitled to receive, provided this information is not required to determine if I am eligible to receive those treatments or benefits or to pay for the services I receive.
Section V - Signature
Is this form being completed by a person with legal authority to act an individual’s behalf, such as a parent or legal guardian of a minor or health care agent, please complete the following information:

No, I am completing this form myselfYes, someone else with legal authority is completing this form.
Signature of Requestor

Clear
Name of Person Completing this Form:

First NameLast Name
Signature of Person Completing this Form

Clear
Describe below how this person has legal authority to sign this form:
Should be Empty:

HIPAA Release Form

Section I - Requestor Information

Section II - Health Information

Section III - Who Can Receive My Health Information

Section IV - Acknowledgements

Section V - Signature