An Authorization for Disclosure of Health Information is an individual's signed permission to allow a covered entity to use or disclose the individual's protected health information (PHI) that is described in the Authorization for the purpose(s) and to the recipient(s) stated in the Authorization.

The form's purpose is to obtain patients signature to be able to use or disclose health information. 

English and Spanish bundled together. 

No need to design your form from scratch, with its contemporary design and host of features, it is sure to enhance any cosmetic practice or existing medical or doctor's office wanting to do away with their old patient intake forms and replace them with new, updated, contemporary forms without going through the expense of starting from a new form or form typesetting and offset printing fees. Print as many as you need and edit them as often as needed.

Fully Editable: The form may be fully personalized to meet your individual or business needs and done as often as needed. Add/edit/personalize your business name, address and contact information, business logo, add your own images to enhance the look of your form or to display your association and certification logos, edit form fields or add your own field questions and obtain the information that you need from your patients, change text size and form ruling color to match your corporate colors or to emphasize important questions.

Languages: English & Spanish versions

Printing: Form may be printed to any desktop, laser or inkjet printer, in color or black and white. Print only what you need to avoid waste. For large print volume, deliver to your local office supply store or local print shop.

Page Size: 8.5" x 11" (Standard US page size)

Program Compatibility: Form is compatible with Microsoft Word 97 and later versions for Windows version and Word for MAC 4.21 and later versions and compatible word processors such as WordPerfect, OpenOffice and LibreOffice.

What Do I Receive?

• Form comes bundled with 
• Microsoft Word Document file (Form) 
• Microsoft Word Template file
• All form assets required, such as, sample images, association logos and free ware fonts -if needed
• Acrobat Reader PDF file
• User Manuals.

Minimum system requirements:

• Microsoft Word 2003 or higher

Software Delivery: This product is downloadable. You will receive the link to download your form by e-mail link as soon as purchase is approved by online processor. Purchases made using 2CheckOut payment processor will take about thirty minutes to be processed; PayPal orders are delivered immediately. If you do not receive expected e-mail, please be sure to check/search your junk or bulk email folders for the email from SnappyFORMS. 

Note: Sample company information displayed on forms such as business name, logo and other images may be replaced with your own image(s) and are only representative of what your form may look like after editing/customizing.

Trademarks: All product names, logos, and brands are property of their respective owners. All company, product and service names used in this website are for identification purposes only. Use of these names, logos, and brands does not imply endorsement. Apple, Mac, Macbook and iMac are trademarks of Apple, Inc., registered in the U.S. and/or other countries. Microsoft, Word are either registered trademarks of Microsoft Corporation in the U.S. and/or other countries.