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Date of Birth: Social Security Number: I authorize and request the disclosure of all protected information for the purpose of review and evaluation in connection 

40+ FREE Medical Record Release Forms (Word | PDF) identity of the requester and confirm that you are authorized to access the required transfer records. In 1996, HIPAA (Health Insurance Portability and Accountability Act) was created as This is a sample of a simple HIPAA release form: Hippa Release Form.pdf  I, or my authorized representative, request that health information regarding my care and treatment as set forth on this form: In accordance with New York State  Welcome to the Agency for Health Care Administration's HIPAA Compliance Office. Our primary function health information. Authorization Form [181 KB, PDF]. Health Insurance Portability and Accountability Act of 1996 (HIPAA) authorization: as Required By Law, Public Health issues as required by law, We welcome your comments: Please feel free to call us if you have any questions about how  The HIPAA Privacy Rule. and sets limits and conditions on the uses and disclosures that may be made of such information without patient authorization. Complying with the HIPAA privacy rule may seem trickier than pulling a rabbit out The sample authorization form that can be downloaded here can be adapted 

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