WP E-Signature by Approve Me - Sign Documents Using WordPress -

HIPAA

LOUIS LAW GROUP

290 NW 165th Street, Suite M-500, Miami, FL 33169

Telephone: (954) 676-4179 | Facsimile: (833)274-8637│Email: [email protected]

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) COMPLIANT REQUEST FORM

Section A: This section must be completed for all Authorizations

, , ,

Medical Sheets

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Timestamp

Audit

January 7, 2020 2:25 pm EDT

HIPAA Uploaded by - IP 173.162.69.149