Hipaa Authorization (Page 3 of 4) in pdf

Instructions to the Authorized Recipients

An Authorized Recipient shall have the right to bring a legal action in any applicable

forum against any covered entity that refuses to recognize and accept this Authorization

for the purposes that I have expressed.

Additionally, an Authorized Recipient is

authorized to sign any documents that the Authorized Recipient deems appropriate to

obtain use, disclosure or release of the protected medical information.

Effect of Duplicate Originals or Copies

If this Authorization has been executed in multiple counterparts, each counterpart

original will have equal force and effect.

An Authorized Recipient may make

photocopies of this Authorization and each photocopy will have the same force and

effect as the original.

My Waiver and Release

With regard to information disclosed pursuant to this Authorization, I waive any right of

privacy that I may have under the authority of the Health Insurance Portability and

Accountability Act of 1996, Public Law 104-191 (HIPAA), any amendment or successor

to that Act, or any similar state or federal act, rule or regulation. In addition, I hereby

release any covered entity that acts in reliance on this Authorization from any liability

that may accrue from the use or disclosure of my protected medical information in

reliance upon this Authorization and for any actions taken by an Authorized Recipient.

Severability

I intend that this authorization conform to United States and Texas law. In the event

that any provision of this document is invalid, the remaining provisions shall nonetheless

remain in full force and effect.

I understand that I have the right to receive a copy of this authorization.

I also

understand that I have the right to revoke this authorization and that any revocation of

this authorization must be in writing.

Dated: __________________

____________________, Principal

SSN: _________________

DOB: _________________

____________________________________________________________________________________

HIPAA AUTHORIZATION FOR _____________________

PAGE 3

Hipaa Authorization Page 3