Sample Hipaa Authorization Form printable pdf download

HIPAA AUTHORIZATION FORM

THIS FORM IS SO WE HAVE YOUR PERMISSION TO SHARE YOUR INFORMATION WITH YOUR INSURANCE

COMPANY SO THAT CLAIMS CAN BE PAID

►

Patient’s Full Name

Patient’s Social Security Number/Medical Record Number

►

Patient’s Date of Birth

Address

►

Patient’s Telephone Number

City, State Zip Code

I hereby authorize use or disclosure of protected health information about me as described below.

The following specific person/class of person/facility is authorized to use or disclose information about me:

_______________________________________________________________________________________________________________

The following person (or class of persons) may receive disclosure of protected health information about me:

A Family Dental Group

His/her/its Name

484 Washington Ave

Address

Belleville NJ 07109

City, State Zip Code

The specific information that should be disclosed is (please give dates of service if possible):

____________________________________________________________________________________________________________

UNLESS YOU SIGN HERE, NO INFORMATION ABOUT ALCOHOL/SUBSTANCE ABUSE, HIV/AIDS, OR MENTAL HEALTH

WILL BE DISCLOSED:

YES, DISCLOSE THIS INFORMATION *______________________

NO, DO NOT DISCLOSE THIS INFORMATION * ______________________

I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it,

and would then no longer be protected by federal privacy regulations.

I may revoke this authorization by notifying _______________________________ in writing of my desire to revoke it. However, I

understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those

actions.

My purpose/use of the information is for ___________________________________________________________________________ .

This authorization expires on 1 YEAR from today OR upon occurrence of the following event that relates to me or to the purpose of the

intended use or disclosure of information about me: _____________________________________.

FEES FOR COPIES: Federal and state laws permit a fee to be charged for the copying of patient records. You may be required to

pre-pay for the copies; if not, then your copies will be mailed along with an invoice.

THIS FORM MUST BE FULLY COMPLETED BEFORE SIGNING – note that signature is required in two places.*

►___________________________________________

_______________________________

___________________________________

Date of Individual’s Signature

Signature of Individual*

Date of Birth or

(The person about whom the information relates)

Social Security Number

OR, if applicable –

►_______________________________________

_______________________________

___________________________________

Date of Guardian’s/Personal

Signature of Guardian* or

Description of Authority to Act

Personal Representative of Patient’s Estate

Representative’s Signature

for the Individual

A copy of this completed, signed and dated form must be given to the Individual or other signator.

Official Use Only

Received

Processed By

Log #

Sample Hipaa Authorization Form

Related Articles

Related forms

Related Categories