Hipaa Authorization printable pdf download

Hipaa Authorization

Authorization for Release of

________________’S

Protected Health Information

(Valid Authorization Under 45 CFR Chapter 164 and the "Texas

Health and Safety Code")

Statement of Intent: It is my understanding that Congress passed a law entitled the

Health Insurance Portability and Accountability Act (“HIPAA”) that limits use, disclosure

or release of my health information (or, sometimes herein, “protected medical

information”). I am signing this Authorization because it is crucial that my health care

providers readily use, release or disclose my protected medical information to, or as

directed by, that person or those persons designated in this Authorization to allow them

to discuss with, and obtain advice from, others or to facilitate decisions regarding my

health care when I otherwise may not be able to do so without regard to whether any

health care provider has certified in writing that I am “incompetent” for purposes of the

"Texas Health and Safety Code":

Appointment of Authorized Recipients

I, _____________________________, an individual, hereby appoint the following

persons, or any of them, as Authorized Recipients for health care disclosure under the

Standards for Privacy of Individually Identifiable Health Care Information (45 CFR Parts

160 and 164) under the Health Insurance Portability and Accountability Act of 1996

(“HIPAA”) and the "Texas Health and Safety Code":

_________________

Grant of Authority

Therefore, I authorize a health care provider (a “covered entity” as defined by HIPAA) to

use, release and disclose my individually identifiable health information in accordance

with and as authorized by 45 CFR Sec(s). 164.502(a)(1)(i) and (iv), 164.502(a)(2)(i),

164.524 and 164.528.

I specifically authorize:

____________________________________________________________________________________

HIPAA AUTHORIZATION FOR _____________________

PAGE 1

Hipaa Authorization