Hipaa Representative Form printable pdf download

Yale University

HIPAA Representative Form

I understand that by voluntarily signing this form I am identifying, authorizing and granting permission to the HIPAA

Representative named below to have authority to access to my protected health information (PHI) to assist in my care. I

am also aware that I may limit access to my records if I specify below:

Patient Information – Please Print

Patient Name: ________________________________________

Date of Birth: _________________________

Street Address: ___________________________________

Town, State, Zip Code: _______________________

Phone Number: ____________________________

MRN/IDX# (if known): ____________________________

HIPAA Representative Information - Please Print

Name: _____________________________________________

Date of Birth: _________________________

Street Address: ___________________________________

Town, State, Zip Code: _______________________

Phone Number: ____________________________

Relationship to Patient:______________________________

I grant to the HIPAA Representative named above access to:

___All of my PHI – note separate box below is also required for HIV, psychiatric and substance abuse access.

___Other - Specify limits or specific health care incident ___________________________________________________

By checking the appropriate categories and by signing this box I (patient) am granting my HIPAA Representative access

to additional health information:

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 box, I am specifically authorizing my HIPAA Representative access to information

relating to:

Substance Abuse (including alcohol/drug abuse)

Mental Health

Psychotherapy Notes

HIV related information (including AIDS 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 as provided in these statutes.

Signature of Patient for this box: _____________________________________________

Date: _____________________

1. I understand that I may revoke this HIPAA Representative designation at any time by notifying the appropriate Yale

University Department/Physician in writing; however, if I do revoke the authorization, it will not have any effect on

any actions taken by Yale University 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 information disclosed pursuant to this form may be redisclosed by the recipient and no longer

protected by HIPAA.

4. 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: _____________

Signature of HIPAA Representative: ______________________________________Date: __________________

(Form will not be valid unless all appropriate blanks are filled) *YOU MAY REFUSE TO SIGN THIS FORM*

11/18/2013 revision

Hipaa Representative Form

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