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 give my permission for Nomi Health 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 Nomi Health permission to:

Other
Form of Disclosure
Section III - Who Can Receive My Health Information
I give authorization for the health information detailed in section II of this document to be shared with the following entities:
Section IV - Acknowledgements
Please acknowledge the following by selecting the check box next to each.
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:
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