Hipaa Form 3 - General Or Psychotherapy Note Authorization

Download a blank fillable Hipaa Form 3 - General Or Psychotherapy Note Authorization in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Hipaa Form 3 - General Or Psychotherapy Note Authorization with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

2111 Exchange Street
Astoria, Oregon 97103
Tel: 503-338-7528
Fax: 503-325-6841
GENERAL OR PSYCHOTHERAPY NOTE AUTHORIZATION
Purpose: This form is used to authorize us to use or disclose protected health information or for another person to
disclose protected health information to us for the purpose stated.
To offset the cost associated with copying, equipment, and supplies, there will be a $15.00 charge for records that
must be paid prior to delivery.
SECTION A: Individual authorizing use and/or disclosure.
Name:
Address:
Telephone:
DOB:
Medical Record Number:
Social Security Number:
SECTION B: The use and/or disclosure being authorized.
Date of service
Operative report
_____________________
Sent To:
From
Lab Reports
_____________________
_________________________________________________
X-Ray Film/Reports _____________________
Individual/Facility / Agency
EKG/EEG
_____________________
Emergency Room
_____________________
_________________________________________________
Address
Discharge Summary _____________________
Physical Therapy
_____________________
_________________________________________________
History and Physical _____________________
City / State / Zip
Progress Notes
_____________________
_________________________________________________
Billing Information
_____________________
Tel Number
Other*
_____________________
_________________________________________________
(*specify)____________________________________
Fax Number
I specifically release the following:
HIV/AIDS/STD's ________
Drug/Alcohol/Mental Health Dx & Tx ________
Genetic Info ________
(Initials)
(Initials)
(Initials)
PATIENT'S SIGNATURE.
I have had full opportunity to read and consider the contents of this authorization, and I understand that, by signing this form, I
am confirming my authorization of the use and/or disclosure of my protected health information, as described in this form.
Patient Signature/Representative:______________________________________________Date: _______________
Personal Representative’s Name:
(Please print)
Relationship to Individual:
Witness:
Purpose of this Authorization:
Insurance
Continuing Care
Legal
Other:__________________________________
1
HIPAA Form 3
Revised 04-20-05

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go
Page of 2