Heartland Women's Healthcare
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Hippa For Minors

Hippa
AUTHORIZATION FOR RELEASE OF INFORMATION
(Patient) or ( Legal Guardian if Patient is a minor)
hereby authorize the following person(s) to receive any disclosures of health information regarding
(Patients Name)
including but not limited to my account charges and balances, exam findings, laboratory and ultrasound results
Name
Relation
Name
Relation
Name
Relation
Name
Relation
I understand that I may alter or revoke, in writing, this authorization at any time. I further understand that any such alteration/revocation does not apply to any previously authorized use or disclosures of my health information, which have already been enacted in trust on this authorization.

I acknowledge, by my signature; I comprehend and understand the full scope of this authorization including any and all restrictions and/or permissions relegated within.

This authorization will expire on year from the date of my signature.

1-877-USAOBGYn

1-877(456-2496)

info@usaobgyn.com

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