Authorization For Release Of Protected Health Information Form Page 2
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1
2I understand that the health care provider(s) listed in Part 2 and/or the State of Delaware
Employee Health Care Plan will not condition treatment, payment, enrollment or
eligibility on the provision of this Authorization. However, I understand that the State of
Delaware may deny my request if I fail to sign this Authorization and provide my health
information that is necessary to support my request.
I understand that I have the right to revoke this Authorization, in writing, at any time, by
sending the revocation to the person or entity authorized to release the information in Part
2, and that the revocation will be effective except to the extent that the person or entity
releasing the information has already taken action in reliance on my Authorization.
I also understand that, if I revoke this Authorization and therefore do not provide the
State of Delaware with the information necessary to support My Request, the State of
Delaware may deny My Request.
I understand that, once disclosed, it is possible that the health information may be further
disclosed by the recipient and no longer subject to protection under federal HIPAA
privacy rules. However, I also understand that the recipient will protect my health
information in accordance with other applicable laws and the State of Delaware’s internal
privacy policies. I have received a copy of my signed Authorization.
Signature: ___________________________________ Date: _________________
[If signing as the personal representative of the person in Box 1, print your name and
describe your authority to sign for the person]:
Name: _____________________________________
Authority: ______________________________________________
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