Hipaa Authorization Form printable pdf download

Pt Chart #____

HIPAA AUTHORIZATION

Patient Name: ______________________________________ Date of Birth: ________________

Cell Phone: _______________________ Home Phone: ________________________________

By signing below, I acknowledge that in accordance with the Privacy Rule of the Health

Insurance Portability and Accountability Act (HIPAA) of 1996, that I have the right to revoke

this consent, in writing, except to the extent that Burkhart & Chapp Chiropractic (BCC) has

taken action in reliance on this consent.

With this consent, BCC can call me at home or an alternate location and leave a message on

voice mail or in person in reference to any items that assist the practice in carrying out treatment,

payment, or healthcare operations (TPO), such as appointment reminders, obtaining insurance

information, billing, and any calls pertaining to my clinical care. Burkhart & Chapp Chiropractic

also has my consent to mail any items that assist the practice in carrying out TPO, such as

appointment reminder cards, statements, and insurance information. I am consenting to BCC,

the use of my Protected Health Information (PHI) to carry out the TPO.

I also understand that BCC will uphold the privacy of my medical records unless this

information is requested to be released by myself or someone who I have given permission to

access my records. I am also fully aware that Burkhart & Chapp Chiropractic will not share my

medical records with anyone without an authorization, except in the event of an emergency or

patient’s condition that deems the situation medically necessary.

I authorize the following individual(s) to receive information pertaining to any medical history

and treatment received:

Name:_________________________________

Relationship ___________________

Name:_________________________________

Relationship ___________________

By signing my name below, I acknowledge my understanding of the terms of this agreement.

This authorization shall supersede any prior written authorization I have made regarding the use,

disclosure, and release of my medical information. This authorization will expire 2 years from

the date it is signed.

____________________________________

Date _________________________

Signature of Patient or Personal Representative

Scanned ___________

EMR Entry __________

Revised MO 11-21-12

Hipaa Authorization Form