Hipaa Authorization Form (Page 2 of 2) in pdf

Each designated representative shall have co-equal authority to request and

receive health information and is not required to act jointly with the other designated

representatives, if any.

By signing this authorization, I acknowledge that the health information used or

disclosed pursuant to this authorization may be subject to re-disclosure by one or more of the

designated representatives, and the health information once disclosed will no longer be protected

by HIPAA or the rules promulgated under HIPAA. No covered entity shall require any

designated representative to indemnify the covered entity or agree to perform any act in order for

the covered entity to comply with this authorization.

I release any covered entity that acts in reliance on this authorization from any

liability that may accrue from releasing any of my health information and for any actions taken

by one or more of the designated representatives.

Each designated representative is authorized to bring a legal action in any

appropriate forum against any covered entity that refuses to recognize and accept this

authorization. Additionally, each designated representative is authorized to sign any documents

that he or she deems appropriate to obtain the health information.

This authorization shall terminate on the first to occur of: (1) two years following

my death or (2) upon my written revocation actually received by the covered entity. Proof of

receipt of my written revocation may be by certified mail, registered mail, facsimile, or any other

receipt evidencing actual receipt by the covered entity. This revocation shall be effective upon

the actual receipt of the notice by the covered entity except to the extent that the covered entity

has taken action in reliance on it. This authorization is not affected by my subsequent disability

or incapacity.

10.

A copy or facsimile of this original authorization shall be accepted as though it

were an original document.

Signed _______________________, 20__.

______________________________________

The State of Texas

County of _______________

This instrument was acknowledged before me on _______________, 20___, by

_______________________.

_________________________________________

Notary Public, State of Texas

HIPAA Authorization

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Hipaa Authorization Form Page 2