Hipaa Authorization Form

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HIPAA Authorization
My name is ___________________________. I reside at _____________________
_____________________________. Despite the provisions of the Health Insurance Portability
and Accountability Act ("HIPAA"), I want my health care providers to provide any and all of my
protected medical information which any of the following named designated representatives may
request to the designated representative making the request. Therefore, I am making this
authorization pursuant to HIPAA and the regulations promulgated under HIPAA, including 45
CFR 164.501 and 45 CFR Sec. 164.508.
1.
In this authorization:
1.1.
A "covered entity" shall mean any health care provider as defined by
HIPAA, including but not limited to a doctor (including but not limited to a physician, podiatrist,
chiropractor, or osteopath), psychiatrist, psychologist, dentist, therapist, nurse, hospital, clinic,
pharmacy, laboratory, ambulance service, assisted living facility, residential care facility, bed
and board facility, nursing home, medical insurance company or any other health care provider
or affiliate.
1.2.
"Health information" means any and all information described in or
protected by HIPAA, including but not limited to any and all health care information, reports
and/or records concerning my medical history, condition, diagnosis, testing, prognosis,
treatment, billing information and identity of health care providers, whether past, present or
future and any other information which is in any way related to my health care.
1.3.
A "designated representative" shall mean a person named in Paragraph 4
below.
2.
I authorize and direct each covered entity to disclose to any one or more of the
designated representatives any and all health information he or she may request.
3.
I also authorize and direct each covered entity, together with its employees and
other agents, to discuss my health information with one or more of the designated representatives
and to answer questions about my health information which any of the designated representatives
may ask, whether or not I am incapacitated at the time.
4.
My designated representatives are:
Name: _________________________________
Address: ________________________________
________________________________________
Phone: __________________________________
Name: _________________________________
Address: ________________________________
________________________________________
Phone: __________________________________

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