3 minutes to complete
To complete the HIPAA Release of Information Form, you must be a patient or authorized representative of the patient, provide accurate personal information, specify the information to be disclosed and to whom, sign and date the form, and understand the potential consequences of releasing the information.
Name of patient
Name of healthcare provider/organization authorized to release information.
Address of releasing provider/organization
Name of person/organization authorized to receive information
Address of recipient
What information may be released? (check all that apply)
Do you want sensitive records included (e.g., mental health, substance use, HIV/AIDS status)?
Reason for releasing this information.
This release is valid until date.
Do you understand that you may revoke this release at any time by submitting a written request?
Do you understand that once information is disclosed, it may be re-disclosed by the recipient and may no longer be protected by HIPAA?
I authorize the release of my health information as specified in this form.
BlockSurvey puts privacy and security above anything else. The use of end-to-end encryption is not a gimmick as in many products; it's a core feature enabling privacy and security. The survey building tools are impeccable. I've used numerous SaaS survey tools, and nothing comes close.
This platform goes far beyond basic surveys. I’ve used it for lead generation, landing page enrichment, and even embedded videos. Everything’s easy to use, well documented, and super flexible—whether you're building forms, quizzes, or something more advanced.
Uses end-to-end encryption technology that allows users to create survey forms where data is secure and private. UI looks very beautiful.
For our NGO, data privacy is everything—and this platform nails it. It keeps personal info fully protected while letting us design beautiful, chat-like surveys that increase engagement. Team collaboration features sealed the deal.
From end-to-end encryption-level security and AI-generated questions to powerful logic flows and white-label domains, BlockSurvey has it all. It’s secure, innovative, and packed with features like calculations, templates, and in-app analytics. I use it to create personalized assessments for leadership training—nothing else compares.
BlockSurvey is very user-friendly with amazing customization options. It makes capturing data simple and secure. While the Web3 space still has room to mature, the platform itself is smooth and intuitive.
Creating surveys with BlockSurvey has been a breeze. The drag-and-drop interface is intuitive, and we’re able to collect data anonymously and securely—without intermediaries. It’s interactive, friendly, and encourages high participation while protecting user privacy. The reports are solid, and we’ve used it confidently for internal and external feedback.
Few tools combine data confidentiality and form aesthetics like this one. The conversational design improved my response rate by 43%, and the webhook integrations made syncing to our CRM effortless. I also love how responsive and community-driven the support team is.
I think BlockSurvey is good for short and long surveys. What I find the best is the fact that there are so many templates I can use and customize.
