Hipaa Form 3 - General Or Psychotherapy Note Authorization Page 2
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2Effect of Granting this Authorization: The protected health information described below may be disclosed to and/or
received by persons or organizations that are not health plans, covered health care providers or health care
clearinghouses subject to federal health information privacy laws. They may further disclose the protected health
information, and it may no longer be protected by federal health information privacy laws.
SECTION C: Expiration and revocation.
Expiration: This authorization will expire one year from date of authorization or:
On _____/_____/_________
Right to Revoke: I understand that I may revoke this authorization at any time by giving written notice of my
revocation. I understand that revocation of this authorization will not affect any action you took in reliance on this
authorization before you received my written notice of revocation.
Entities Authorized to Receive: Name or specifically identify the persons and/or organizations to whom you are
authorizing the disclosure and subsequent use of the protected health information described above:
Name
Relationship
Tel#
Name
Relationship
Tel#
Name
Relationship
Tel#
Name
Relationship
Tel#
Patient Care Partner
Relationship
Tel#
SECTION D: Psychotherapy notes.
Check if this authorization is for psychotherapy notes.
If this authorization is for psychotherapy notes, you must not use it as an authorization for any other type of
protected health information.
YOU ARE ENTITLED TO A COPY OF THIS AUTHORIZATION AFTER YOU SIGN IT.
FOR HOSPITAL USE
Date Prepared:__________ Initial: ________
Pt. Pick-Up
Mailed
Faxed Date of release:_________
Include this authorization in the individual’s medical records.
Verification of ID:
Photo ID
Person is known to me
Government Credentials e.g. Badge
Verified by: (CMH Staff Signature):_______________________________________________________________
Medical Record Number________________________
2
HIPAA Form 3
Revised 04-20-05
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