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HIPAA Waiver
I, the undersigned, hereby waive my HIPAA protections and authorize the use of my personal health information (PHI) under the following conditions:
I agree to release {medical information} between {date} and {date} to {Name/Company/Organization}. The purpose of this disclosure is {purpose}, and I do not authorize any other uses for it.
If the medical information is shared with others or released to the public, I require the following adjustments: {anonymity, name change, certain information withdrawn}.
The authorization for this medical information begins on {date} and expires on {date}. I understand that I may revoke this authorization at any time in writing.
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Signature & date
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