Medium

Available on

Apple Android Windows

Privacy and Confidentiality Release Form Mobile App

The Privacy and Confidentiality Release Form mobile app makes it easy to create an electronic medical release form using a smartphone or tablet. Once signed by the patient, the healthcare release form allows individuals to discuss your medical information and claims with other health care providers as well as insurance providers.

The medical authorization form is perfect for doctors' offices, hospitals and clinics who are required by law to protect patient health records. The helpful health information management and release form app tracks patient insurance information, treatments received and more.

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

Want to learn more about GoCanvas?

Request a Demo

Take a peek inside the Privacy and Confidentiality Release Form Mobile App

Included Features

Our App Builder gives you the power to easily add and remove the ones you want. {{controller.show_all ? 'See included features.' : 'See more features.'}}

  • {{data.title}}

Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico statictext

    By completing this form, you are providing your consent to (Company) to discuss your claim activi...

  • Ico textbox

    I authorize (Company) to discuss my claim activity with

  • Ico integer

    This authorization is valid for_(months from the date signed.

  • Ico statictext

    I give (Company) permission to release any or all of the following information:

  • Ico checkbox

    All financial and claim information related to medical bills or Claimant’s Statement and Authoriz...

  • Ico checkbox

    Provider name, date of service, total charge, total paid and date of payment.

  • Ico checkbox

    Insurance ID number and/or social security number.

  • Ico statictext

    Under no circumstances can (Company) release medical information obtained from your physician or ...

  • Ico textbox

    Patient Name

  • Ico textbox

    Insurance ID Number

  • Ico signature

    Signature of the Patient or Insured Person if the patient is a minor child

  • Ico date

    Date

  • ...and More!

Related Professional Services Apps... and they're all free for GoCanvas subscribers!

App Name

Medical Students & Instructors Statem...

Due to the nature of the hospital healthcare environment, student experience may be exposed to privileged information conc...

App Name

Hospital Confidentiality Statement

Hospitals staff can use the Hospital Confidentiality Statement mobile app to read and acknowledge that they understand the...

App Name

HIV Confidentiality Technical Guidelines

While all data collected, stored and used as part of scaling-up HIV services in countries have confidentiality and securit...

App Name

Health Care Confidentiality Statement

This Health Care Confidentiality Statement Mobile App enables health care employees to read and agree to comply with the t...

App Name

HIV Confidentiality Summary tasks for...

Organizations at all levels of the healthcare system must identify a professional to be ultimately responsible for the con...

App Name

Breaches of Health Care Confidentiali...

Patient confidentiality, privacy laws and HIPAA are to be complied with at all times in the Health Care Industry. Failure ...

App Name

Client Information and Consent for Co...

The Client Information and Consent for Counseling Services Confidentiality mobile app was deigned to be used by universiti...

App Name

Disclosures of Protected Health Infor...

This Disclosures of Protected Health Information Mobile App details patient confidentiality and rights, as well as policie...

More Information


Related Blog Posts