Hipaa Authorization For Release Of Information printable pdf download

Hipaa Authorization For Release Of Information

HIPAA Release

Phone: 1.844.800.5777 Fax: 1.844.800.5770

AUTHORIZATION FOR RELEASE OF INFORMATION

Section A: Must be completed for all authorizations.

I hereby authorize the use or disclosure of my individually identifiable health information as described below. I understand that this

authorization is voluntary. I understand that if the organization authorized to receive the information is not a health plan or health

care provider, the released information may no longer be protected by federal privacy regulations.

Patient Name:

ID Number:

Persons/Organizations providing the information:

Persons/Organizations receiving the information:

Specific description of information (including date(s)):

Section B: Must be completed only if a Health Plan or a Health Care Provider has requested the authorization.

1. The health plan or health care provider must complete the following:

What is the purpose of the use or disclosure?

b. Will the Health Plan or Health Care Provider requesting the authorization receive financial or in-kind compensation in

exchange for using or disclosing the health information described above?



Yes:



No:

2. The patient or the patient’s representative must read and initial the following statements:

I understand that my health care and the payment for my health care will not be affected if I do not sign this form.



Initials_________

b. I understand that I may see and copy the information described on this form if I ask for it, and that I get a copy of this form

after I sign it.



Initials_________

Section C: Must be completed for all authorizations.

The patient or patient’s representative must read and initial the following statements:

1. I understand that this authorization will expire on __________________(DD/MM/YR) Initials:_________

2. I understand that I may revoke this authorization at any time by notifying the providing organization in writing, but if I do it

won't have any affect on any actions they took before they received the revocation. Initials_________

Signature of patient or patient's representative:

Date:

(The Form MUST be completed before signing)

Print Name of patient’s representative:

Relationship to Patient:

Hipaa Authorization For Release Of Information