Hipaa Compliant Authorization For Release Of Patient Information
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2HIPAA Compliant Authorization for Release of Patient Information
Pursuant to 45 CFR 164.508
Section I – Patient Information
Name:
Member ID:
Street Address:
Birth Date:
City:
State:
Zip:
Telephone:
Email:
I, or my authorized representative, hereby authorize Golder Ranch Fire District and their respective
employees to disclose my Personal Health Information (PHI) and Insurance Record to
the designee identified below.
SECTION II –Authorized Designee (to whom the information will be sent)
Name:
Relationship:
Street Address:
Telephone:
City:
State:
Zip:
In accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand
that:
1. This authorization may include disclosure of information relating to ALCOHOL and DRUG
ABUSE, SEXUALLY TRANSMITTED DISEASES, MENTAL HEALTH TREATMENT, except
psychotherapy notes, and CONFIDENTIAL ACQUIRED IMMUNODEFICIENCY SYNDROME
(AIDS), OR HUMAN IMMUNODEFICIENCY VIRUS (HIV) RELATED INFORMATION only if I
place my initials on the appropriate line in Section III. In the event the health information
described below includes any of these types of information, and I initial the line on the box in
Section III, I specifically authorize release of such information to the person indicated in
Section II.
2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health
treatment information, the recipient is prohibited from redisclosing such information without my
authorization unless permitted to do so under federal or state law. I understand that I have the
right to request a list of people who may receive or use my HIV-related information without
authorization.
3. I have the right to revoke this authorization at any time by writing to Freedom Health. I
understand that I may revoke this authorization, except to the extent that action has
already been taken based on this authorization.
4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment
in Freedom Health, or eligibility benefits will not be conditioned upon my authorization of
disclosure.
5. Information disclosed under this authorization might be redisclosed by the recipient,
and the redisclosure may no longer be protected by federal or state law.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY PERSONAL
HEALTH INFORMATION AND INSURANCE RECORD WITH ANYONE OTHER THAN
THE PERSON AUTHORIZED IN SECTION II.
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