DIS100 Two Part Patient Disclosure Authorization HIPAA Form 8 1/2 x 11" QTY 50

DIS100 Two Part Patient Disclosure Authorization HIPAA Form
Size: 8 1/2 x 11"

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

• 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.
• Available in 2 parts only: Yellow, White.
• Meets HIPAA Regulations.
• Carbonless.
• IMPORTANT: Your order will be on hold until you message us the Imprint you want on the form.