Create your own printable contract — FREE!
Formatted and ready to use with Microsoft Word, Google Docs, or any other word processor that can open the .DOC file format.
HIPAA Waiver
I, the undersigned, hereby waive my HIPAA protections and authorize the use of my personal health information (PHI) under the following conditions:
I agree to release {medical information} between {date} and {date} to {Name/Company/Organization}. The purpose of this disclosure is {purpose}, and I do not authorize any other uses for it.
If the medical information is shared with others or released to the public, I require the following adjustments: {anonymity, name change, certain information withdrawn}.
The authorization for this medical information begins on {date} and expires on {date}. I understand that I may revoke this authorization at any time in writing.
____________________________________
Signature & date
Create your own printable contract — FREE!
Formatted and ready to use with Microsoft Word, Google Docs, or any other word processor that can open the .DOC file format.
Index of Printable Contract Examples
DISCLAIMER: The contracts contained on PrintableContracts.com are not to be considered as legal advice. All content is for informational purposes, and Savetz Publishing makes no claim as to accuracy, legality or suitability. The site owner shall not be held liable for any errors, omissions or for damages of any kind.
