Designation Of A Personal Representative And Authorization To Access Protected Health Information Form
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1Yale Health Center
55 Lock St
PO Box 208237
New Haven, CT 06520-8237
Phone (203) 432-7741
Fax (203) 436-5536
Designation of a Personal Representative and Authorization to Access Protected Health Information
This authorization grants permission to the personal representative named below to have access to my protected health information. I hereby
authorize Yale Health clinicians, care team or clinician name __________________________________________to use and disclose my
protected health information. I understand that this authorization is voluntary. I understand that once this information is released to the
personal representative named below, the released information may no longer be protected by federal privacy regulations.
Patient name: _________________________________________________________________________ DOB __________________
Address: __________________________________________________________________________Phone: _____________________
Personal representative _______________________________________________Relationship to patient: ________________________
Address: __________________________________________________________________ Phone: _____________________________
The information will be used or disclosed for the following purposes:
(
) At my request
(
) Other: ___________________________________________________________
Please read the three statements below carefully before signing this document:
1.
I understand that I may revoke this authorization at any time by notifying the Yale Health HIPAA Privacy Office PO Box 208237, New
Haven, CT 06520-8237 in writing; however, if I do revoke the authorization, it will not have any effect on any actions taken by Yale
Health clinicians or care team prior to their receipt of the revocation.
2.
I understand that my treatment or payment for treatment cannot be conditioned on whether or not I sign this authorization:
3.
I understand that this authorization will: (Must check one)
( ) expire 1 year from the date executed; or
( ) be effective for the lifetime of the patient unless revoked (see #1 above)
Signature of Patient _______________________________________________________________ Date _________________________
Witness ________________________________________________________________________ Date__________________________
I understand that this health information may include HIV-related information and /or information relating to diagnosis or treatment of
psychiatric disabilities and/or substance abuse and that by signing this form, I am specifically authorizing the release of information relating to:
( ) Substance Abuse (including alcohol/drug abuse
( ) Mental Health
( ) Psychotherapy Notes
( ) HIV related information (including AIDS and related testing)
The confidentiality of this record is required under Chapter 899 of the Connecticut General Statutes, as well as, Title 42 of the United States
code. This material shall not be transmitted to anyone without written consent or authorization provided in these statutes.
Signature of Patient __________________________________________________________________ Date ___________________________
Signature of personal representative ________________________________________________ Date _________________________
(Form will not be valid unless all appropriate blanks are filled)
Printed name of personal representative: __________________________________________________________________________
Relationship to patient: _________________________________________________________________________________________
Witness______________________________________________________________________Date_____________________________
*YOU MAY REFUSE TO SIGN THIS AUTHORIZATION*
For Department Use Only:
Date received: ________________________________________ By: ______________________
Net ID
Rev.7/12
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