Two-Part Patient Disclosure Authorization HIPAA Form

Item#: DIS100 Size: 8 1/2 x 11"
Quantity 50 100 200 500 1000
DIS100-2  2-Parts/Duplicate $67.99 $87.99 $145.99 $284.99 $529.99
We recommend this quantity.
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Product Benefits and Features

Protect your practice and avoid privacy disputes with this clear, step-by-step form authorizing release of patient information.

  • Personalization includes: Includes your imprinted practice name, address, and phone number, up to 5 lines. 2-part form provides a patient copy and a 2-hole punched permanent record.