HIPAA RELEASE AND AUTHORIZATION
I, ______________________________________________ (Principal), hereby authorize the following person to act as my
agent with regard to the matters specified in this Release:
If the person designated as my agent is unable or unwilling to serve, I designate the following persons as my agent hereunder, who
shall serve in the following order:
First Alternate Agent
Second Alternate Agent
This Release and all of the provisions contained herein are effective immediately. I intend for my agent to be treated as I
would be treated with respect to my rights regarding the use and disclosure of my individually identifiable health information and other
medical records. This Release authority applies to any information governed by the Health Insurance Portability and Accountability Act
of 1996 ("HIPAA"), 42 USC 1320d and 45 CFR 160-164.
I hereby authorize any doctor, physician, medical specialist, psychiatrist, chiropractor, health-care professional, dentist, optometrist,
health plan, hospital, hospice, clinic, laboratory, pharmacy or pharmacy benefit manager, medical facility, pathologist, or other provider
of medical or mental health care, as well as any insurance company and the Medical Information Bureau Inc. or other health-care
clearinghouse that has paid for or is seeking payment from me for such services (referred to herein as a "covered entity"), to give,
disclose and release to my agent who is named herein and who is currently serving as such, without restriction, all of my individually
identifiable health information and medical records regarding any past, present or future medical or mental health condition, including
all information relating to the diagnosis and treatment of HIV/AIDS, sexually transmitted diseases, mental illness, and drug or alcohol
abuse. Additionally, this disclosure shall include the ability to ask questions and discuss this protected medical information with the
person or entity who has possession of the protected medical information even if I am fully competent to ask questions and discuss this
matter at the time. It is my intention to give a full authorization to any protected medical information to my agent.
In determining whether I am incapacitated, all individually identifiable health information and medical records shall be released to my
agent, including any written opinion relating to my incapacity that my agent may have requested. This release authority applies to any
information governed by HIPAA and applies even if my agent has not yet begun serving as my agent.
The authority given to my agent shall supersede any prior agreement that I may have made with my health-care providers to restrict
access to or disclosure of my individually identifiable health information. The individually identifiable health information and other
medical records given, disclosed, or released to my agent may be subject to redisclosure by my agent and may no longer be protected
This Release 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, electronic
mail, or any other receipt evidencing actual receipt by the covered entity. This Release shall not be affected by my subsequent
disability or incapacity. There are no exceptions to my right to revoke this Release.