{"product_id":"dis100-two-part-patient-disclosure-authorization-hipaa-form-8-1-2-x-11","title":"DIS100 Two Part Patient Disclosure Authorization HIPAA Form 8 1\/2 x 11\"","description":"\u003cspan style=\"font-family: verdana,arial,helvetica; font-size: 12pt; color: #990000;\"\u003e\u003cb\u003e\u003cspan style=\"font-size: large;\"\u003eDIS100 Two Part Patient Disclosure Authorization HIPAA Form\u003c\/span\u003e\u003cbr\u003e \u003c\/b\u003e\u003c\/span\u003e\u003cspan style=\"font-family: verdana,Arial,Helvetica; font-size: medium;\"\u003e\u003cb\u003eSize: \u003c\/b\u003e\u003cspan style=\"font-weight: bold;\"\u003e8 1\/2 x 11\"\u003c\/span\u003e\u003c\/span\u003e\u003cspan style=\"font-size: 12pt;\"\u003e\u003cspan style=\"font-size: 12pt;\"\u003e\u003c\/span\u003e\u003c\/span\u003e\u003cp\u003e\u003cspan style=\"font-family: verdana, geneva; font-size: medium;\"\u003eProtect your practice and avoid privacy disputes with this clear, step-by-step form authorizing release of patient information.\u003cbr\u003e\u003cbr\u003e\u003c\/span\u003e\u003c\/p\u003e\u003cul style=\"font-family: Century Gothic;\" type=\"square\"\u003e\n\u003cli style=\"font-family: Century Gothic;\"\u003e\u003cspan style=\"font-size: medium; font-family: verdana, geneva;\"\u003eIncludes your imprinted practice name, address, and phone number, up to 5 lines. 2-part form provides a patient copy and a 2-hole punched permanent record.\u003c\/span\u003e\u003c\/li\u003e\n\u003cli style=\"font-family: Century Gothic;\"\u003e\u003cspan style=\"font-size: medium; font-family: verdana, geneva;\"\u003e\u003cstrong\u003eAvailable in 2 parts only: Yellow, White.\u003c\/strong\u003e\u003c\/span\u003e\u003c\/li\u003e\n\u003cli style=\"font-family: Century Gothic;\"\u003e\u003cspan style=\"font-size: medium; font-family: verdana, geneva;\"\u003eMeets HIPAA Regulations.\u003cbr\u003e \u003c\/span\u003e\u003c\/li\u003e\n\u003cli style=\"font-family: Century Gothic;\"\u003e\u003cspan style=\"font-size: medium; font-family: verdana, geneva;\"\u003eCarbonless.\u003cbr\u003e\u003c\/span\u003e\u003c\/li\u003e\n\u003cli style=\"font-family: Century Gothic;\"\u003e\u003cspan style=\"font-size: medium; font-family: verdana, geneva;\"\u003eImprint area: 4 x 1\"\u003c\/span\u003e\u003c\/li\u003e\n\u003cli style=\"font-family: Century Gothic;\"\u003e\u003cspan style=\"font-size: medium; font-family: verdana, geneva;\"\u003e100% Satisfaction Guarantee.\u003cbr\u003e \u003c\/span\u003e\u003c\/li\u003e\n\u003cli style=\"font-family: Century Gothic;\"\u003e\u003cspan style=\"font-size: medium; font-family: verdana, geneva;\"\u003eHigher quantities are available at discounted prices. \u003cbr\u003e \u003c\/span\u003e\u003c\/li\u003e\n\u003cli style=\"font-family: Century Gothic;\"\u003e\u003cspan style=\"font-size: medium; font-family: verdana, geneva;\"\u003eSpeak to a customer service specialist at 855-5FORMS5 or 855-536-7675. 9AM - 7PM EST Monday - Thursday and 9AM - 5PM EST on Friday.\u003c\/span\u003e\u003c\/li\u003e\n\u003c\/ul\u003e\u003cspan style=\"font-size: medium; font-family: verdana, geneva;\"\u003e\u003cbr\u003e\u003c\/span\u003e\u003cspan style=\"font-size: 12pt;\"\u003e\u003cspan style=\"font-family: verdana, geneva; font-size: medium;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 12pt;\"\u003e\u003cspan style=\"font-family: verdana, geneva; font-size: medium;\"\u003eI\u003c\/span\u003e\u003c\/span\u003emportant: \u003c\/strong\u003eEnter your printable text \u003cstrong\u003eexactly \u003c\/strong\u003eas you would like it to appear, using only the lines that you need. Please check for accuracy. Please be sure to double-check your spelling, punctuation, abbreviations and all other content.\u003cbr\u003e\u003c\/span\u003e\u003cstrong\u003e\u003c\/strong\u003e\u003cbr\u003e\u003c\/span\u003e\u003cspan style=\"font-family: Century Gothic; font-size: 10pt;\"\u003e\u003c\/span\u003e","brand":"NEBS","offers":[{"title":"50 - HIPAA Forms","offer_id":42383678668859,"sku":"DIS100-2","price":39.38,"currency_code":"USD","in_stock":true},{"title":"100 - HIPAA Forms","offer_id":42383678570555,"sku":"DIS100-2","price":57.09,"currency_code":"USD","in_stock":true},{"title":"200 - HIPAA Forms","offer_id":42383678636091,"sku":"DIS100-2","price":90.56,"currency_code":"USD","in_stock":true},{"title":"500 - HIPAA Forms","offer_id":42383678701627,"sku":"DIS100-2","price":180.47,"currency_code":"USD","in_stock":true},{"title":"1000 - HIPAA Forms","offer_id":42383678603323,"sku":"DIS100-2","price":339.28,"currency_code":"USD","in_stock":true}],"thumbnail_url":"\/\/cdn.shopify.com\/s\/files\/1\/0618\/8462\/9051\/files\/DIS100.1.jpg?v=1754997005","url":"https:\/\/5forms.com\/products\/dis100-two-part-patient-disclosure-authorization-hipaa-form-8-1-2-x-11","provider":"5Forms-LLC","version":"1.0","type":"link"}