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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
  • oxy
  • Red Bull
  • Mirvac

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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.'}}

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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!

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