Compliant Authorization Form printable pdf download

HIPAA COMPLIANT AUTHORIZATION

Patient name: ___________________________________________ Date of Birth: _______________

Previous name: __________________________________________

I. Authorization

You may use or disclose the following health care information (check all that apply):

All health care information in my medical record

Health care information in my medical record relating to the following treatment or condition:

____________________________________________________________________________

Health care information in my medical record for the dates(s): ___________________________

Other (e.g., x rays, bills), specify date(s): ___________________________________________

You may use or disclose the following health care information regarding testing, diagnosis, and

treatment, should it be found in my records, only if checked below:

HIV (AIDS virus)

Sexually transmitted diseases

Psychiatric disorders/mental health

Drug and/or alcohol use

You may disclose this health care information to:

Name (or title) and organization or category of persons (i.e. all treating physicians, etc.): _________

_______________________________________________________________________________

Address (optional): ____________________ City: _________________ State: ___ Zip: ________

Reason(s) for this authorization (check all that apply):

At my request

Other (specify) __________________________________________

This authorization ends:

On (date): __________________

When the following event occurs: _________________________________________________

In 90 days from the date signed (if disclosure is to a financial institution or an employer of the patient

for purposes other than payment)

II. My Rights

I understand I do not have to sign this authorization in order to get health care benefits (treatment, payment

or enrollment). However, I do have to sign an authorization form:

•

To take part in a research study or

•

To receive health care when the purpose is to create health care information for a third party.

I may revoke this authorization in writing. If I did, it would not affect any actions already taken by the

physician based upon this authorization. I may not be able to revoke this authorization if its purpose was to

obtain insurance. Two ways to revoke this authorization are:

•

Fill out a revocation form.

•

Write a letter to the physician.

Once health care information is disclosed, the person or organization that receives it may re-disclose it.

Privacy laws may no longer protect it.

________________________________________________

________________________________

Patient or legally authorized individual signature

Date

Time

________________________________________________

________________________________

Printed name if signed on behalf of the patient

Relationship (parent, legal guardian,

personal representative)

Compliant Authorization Form

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