Hipaa Compliant Authorization Form For The Release Of Patient (Page 2 of 2) in pdf

Hipaa Compliant Authorization Form For The Release Of Patient Page 2

immunodeficiency virus (HIV), and alcohol and drug abuse. I authorize the release or disclosure

of this type of information.

This protected health information is disclosed for the following purposes: __________________

_____________________________________________________________________________

This authorization is given in compliance with the federal consent requirements for release of

alcohol or substance abuse records of 42 CFR 2.31, the restrictions of which have been

specifically considered and expressly waived.

You are authorized to release the above records to the following representatives of defendants in

the above-entitled matter who have agreed to pay reasonable charges made by you to supply

copies of such records:

____________________________________________________________________________

Name of Representative

_____________________________________________________________________________

Representative Capacity (e.g. attorney, records requestor, agent, etc.)

_____________________________________________________________________________

Street Address

______________________________________________________________________________

City, State and Zip Code

I understand the following:

See CFR §164.508(c)(2)(i-iii)

a. I have a right to revoke this authorization in writing at any time, except to the extent

information has been released in reliance upon this authorization.

b. The information released in response to this authorization may be re-disclosed to other

parties.

c. My treatment or payment for my treatment cannot be conditioned on the signing of this

authorization.

Any facsimile, copy or photocopy of the authorization shall authorize you to release the records

requested herein. This authorization shall be in force and effect until two years from date of

execution at which time this authorization expires.

________________________________________

______________________

Signature of Patient or Legally Authorized Representative

Date

(See 45CFR § 164.508(c)(1)(vi))

_____________________________________________________________________________

Name and Relationship of Legally Authorized Representative to Patient

(See 45CFR §164.508(c)(1)(iv))

___________________________________________

______________________

Witness Signature

Date

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Hipaa Compliant Authorization Form For The Release Of Patient Page 2