Hipaa Authorization Form printable pdf download

Promise Community Health Center

HIPAA Authorization Form

Promise Community Health Center (PCHC) has taken measures to protect all of our patients' private medical

information. PCHC will not release any information to anyone unless you have provided the requested

information below. These would be people other than what is covered in our Notice of Privacy Practices.

Your protected health information will be used by PCHC or disclosed to others for the purpose of treatment,

obtaining payment, or supporting the day-to-day health care operations of the practice. You should review the

Notice of Privacy Practices for a more complete description of how your protected health information may be

used or disclosed. You may review the notice prior to signing this consent. You may also request a copy of the

Notice of Privacy Practices for your own records. See the receptionist to receive a copy.

You may request a restriction on the use or disclosure of your protected health information. PCHC may or may

not agree to restrict the use or disclosure of your protected health information. If PCHC agrees to your

request, the restriction will be binding on the practice. Use or disclosure of protected information in violation

of an agreed upon restriction will be a violation of the Federal Privacy Standards.

You may revoke this consent to the use and disclosure of your protected health information. You must revoke

consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation

of consent is received will not be affected. PCHC reserves the right to modify the Privacy Practices outlined in

the notice.

Please see the receptionist with any questions prior to signing this authorization form.

I, _________________________________, DOB ___________ am authorizing the person/people listed below

to obtain medical information about myself. I understand PCHC is not responsible for the information

provided as long as it is given to a person that I have listed below.

Date of Birth must be provided so that our office can verify that we are speaking to the correct person.

Name: ______________________________

Name: _________________________________

Date of Birth: ____________________

I have reviewed this consent form & give my permission to PCHC to Use & Disclose my health information in

accordance of the Federal Privacy Standards.

Patient’s Signature: _________________________________ Date: _______________

If guardian, relationship to patient: _________________________________________

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I, __________________________________, do not authorize PCHC to release any of my protected medical

information to anyone other than the entities that are discussed in the Notice of Privacy Practices.

Patient’s Signature: _____________________________________Date: _____________

If guardian, relationship to patient: _________________________________________

Hipaa Authorization Form