Directory Results for AUTHORIZATION FOR RELEASE OF HEALTH INATION PURSUANT TO HIPAA I authorize (Facility or physician) to disclose protected health information (PHI) contained in or made a part of the health records of: Patient name: Date of Birth: Social to AUTHORIZATION FOR RELEASE OF HEALTH INATION PURSUANT TO HIPAA Patient Name Date of Birth Social Security Number Patient Address I, or my authorized representative, request that health information regarding my care and treatment be