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Medical Information Release Form

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Due to 2003 HIPPA laws, the release of patient’s medical information has been restricted.
On the form below, please list any family member, friend or others we may release information to if they were to call our office and ask questions about an appointment date, surgery date, or any other treatment questions.

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Information Access Preferences (Clinical Information / Financial)
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Information Access Preferences (Clinical Information / Financial)
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Information Access Preferences (Clinical Information / Financial)
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Information Access Preferences (Clinical Information / Financial)
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Information Access Preferences (Clinical Information / Financial)
If you checked the Restricted line above, please specify which clinical information you DO NOT wish to share with the person(s) listed above.
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May we leave a message on an answering machine or voicemail?
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  • I understand that I can grant and/or restrict access to my private health information with Eric L. Hensen, D.O, P.A.
  • Health information is used and disclosed to carry out treatment, payment or operations.
  • I understand that Eric L. Hensen, D.O, P.A. reserves the right to deny this request dependent upon the circumstances

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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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