Last revised: 10/02/2023
Using this Form
A Release of Liability form is typically not related to the Health Insurance Portability and Accountability Act (HIPAA) because it pertains to the legal waiver of certain rights or claims rather than the release of medical information. However, if you want to create a Release of Liability form in a healthcare context where HIPAA compliance may be a consideration, you can include a section specifying that the release pertains solely to liability and does not involve the release of protected health information (PHI).
Please note that the exact requirements for a Release of Liability form may vary by jurisdiction and the specific circumstances involved. Consult with legal counsel or a relevant expert to ensure that your form complies with all applicable laws and regulations, including any state-specific requirements. This template emphasizes that the release pertains to liability and not to the release of protected health information (PHI) under HIPAA.
Here’s a template for such a form:
Release of Liability Form with HIPAA Compliance
Party Providing Release of Liability:
- Full Name/Organization: ________________________________
- Address: ________________________________
- City: ________________________________
- State: ________________________________
- Zip Code: ________________________________
- Phone Number: ________________________________
Party Releasing Liability:
- Full Name: ________________________________
- Date of Birth: ________________________________
- Address: ________________________________
- City: ________________________________
- State: ________________________________
- Zip Code: ________________________________
- Phone Number: ________________________________
Description of Release: I, [Party Releasing Liability’s Full Name], agree to release [Party Providing Release of Liability] from any and all liability, claims, demands, actions, or causes of action that may arise as a result of any activities, events, or interactions related to [describe the context of the release, e.g., medical treatment or participation in a healthcare program] provided by [Party Providing Release of Liability]. This release of liability includes any injuries, damages, or harm that may occur during or as a result of these activities.
HIPAA Compliance Clause: I understand and acknowledge that this release of liability does not include the release of any protected health information (PHI) as defined by the Health Insurance Portability and Accountability Act (HIPAA). I consent to the use and disclosure of my medical information as permitted by applicable laws and regulations.
Revocation: I understand that I have the right to revoke this release of liability in writing at any time.
Governing Law: This Release of Liability form is governed by the laws of the state of [state name].
Signature: I have signed this Release of Liability form willingly and in full understanding of its implications on this [Date].
Party Releasing Liability’s Signature: ________________________________
Witnesses (if required by state law):
- Name: ________________________________ Signature: ________________________________ Date: ________________________________
- Name: ________________________________ Signature: ________________________________ Date: ________________________________