HIPAA Authorization Form

Testing Verification Release

This HIPAA-compliant authorization form allows Transparent Dating to receive your verified STD, HIV, and AIDS testing results directly from your healthcare provider — so your profile can display a trusted verification badge.

Your Privacy Rights Under HIPAA

The Health Insurance Portability and Accountability Act (HIPAA) protects the privacy of your health information. You have the right to authorize or refuse the release of your medical records. This authorization is entirely voluntary. Refusing to sign will not affect your treatment or healthcare benefits. You may revoke this authorization at any time in writing, except where disclosure has already occurred.

1. Your Personal Information

Full Legal Name *

Date of Birth *

Email Address *

Phone Number

Current Address

2. Healthcare Provider / Testing Facility

Provider / Clinic Name *

Provider Phone

Provider Address

3. Connect Your Health App (Optional)

Speed up verification by telling us which patient portal or health app holds your records. We support MyChart, Epic, LabCorp, Quest Diagnostics, and many more. We will never ask for your password — only your patient ID or portal username so our team can request records directly.

4. Information to Be Released

Select all testing results you authorize to be released for verification:

STD (Sexually Transmitted Disease) Testing Results

HIV (Human Immunodeficiency Virus) Testing Results

AIDS (Acquired Immunodeficiency Syndrome) Related Records

Herpes Simplex Virus (HSV-1 / HSV-2) Testing Results

Other (specify)

5. Testing Date Range

Specify the date range of the test(s) to be released:

Test Date From

Test Date To

6. Purpose of Release

Why is this information being released?

7. Consent & Authorization

Authorization Statement

I hereby authorize the healthcare provider named above to release the specified health information to Transparent Dating for the purpose of identity and health verification. I understand that:

This authorization is voluntary and I may refuse to sign without affecting my care.
I may revoke this authorization at any time in writing, except where disclosure has already occurred.
Information disclosed may be subject to re-disclosure by the recipient and may no longer be protected by HIPAA.
Transparent Dating will use this information solely for profile verification purposes.
My information will be stored securely and never sold to third parties.
This authorization expires 12 months from the signature date unless revoked earlier.

I have read and understand the above authorization statement and voluntarily consent to the release of my health information.

8. Signature

Full Name (Electronic Signature) *

By typing your name, you are providing an electronic signature.

Date *

This form is encrypted and transmitted securely. Your health information is protected.