HIPAA Records Release Form HIPAA Records Release Form Date To:*Attn:*Name* First Last Date of Birth* Account Number*Email* Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country I HEREBY GRANT AND AUTHORIZE Ken Kwapiszewski R.Ph. OF Caradigm Patient Advocacy, LLC ACCESS TO ANY MEDICAL RECORDS, REPORTS, CORRESPONDENCE, INSURANCE INFORMATION, AND BILLING INFORMATION AS REQUESTEDFromThroughI authorize Caradigm Patient Advocacy LLC to correspond through any medium with you regarding the above. Should you have any questions, please call Caradigm Patient Advocacy. Please address mailed correspondence to: Ken Kwapiszewski, R.Ph. Caradigm Patient Advocacy, LLC 17525 N Fruitport Rd. Spring Lake MI 49456 Other authorized contact information: Phone: 616-414-4694 Email: firstname.lastname@example.org Please accept a Photostat copy of this authorization with the same authority as the original. Signature*Please type your full name as signature.Date of Signature* Acknowledgement* By my signature above, I acknowledge the release of any Protected Health Information (PHI) to Caradigm Patient Advocacy as designated on this release form. This protected health information is to be disclosed under this authorization at my request, as permitted by 164.508©(1)(iv) of the privacy regulations issued pursuant to the Health Insurance Portability and Accountability Act (“HIPAA Privacy Rule”). I acknowledge that I have received a copy of this authorization. This authorization will remain in effect until revoked. I understand that I have the right to revoke this authorization in writing, at any time, by sending a written request for the revocation to Caradigm Patient Advocacy. NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle AJAX powered Gravity Forms.