Authorization For Release Of Protected Health Information Form

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AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION
I, __________________________________, Social Security Number: __ __ __ - __ __ - __ __ __ __ DOB ___/____/___
Name of client
[optional]
hereby authorize the use and/or disclosure of my individually identifiable health information as described below. I
understand that signing this form is voluntary.
Providing the information:
Receiving the information:
Person(s)/Organization(s)
P
(check all that applies)
erson(s)/Organization(s)
(check all that applies)
____
Community mental health center(s)
____ Aging and Disability Resource Center
_____________________________________
_____________________________________
name
name
____ Kansas Department for Aging and Disability Services
____ Intermediate care facility/nursing facility/hospital
_____________________________________
name
____ State Agency/Department
Other(s): name/address/phone___________________________
_____________________________________
name
____________________________________________
____ Community developmental disability organization(s)
__________________________________________________
_____________________________________
name
__________________________________________________
____ Aging and Disability Resource Center
Other(s): name/address/phone_____________________
__________________________________________________
_________________________________________________
Description of Information to be Used or Disclosed:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
The purpose of the Use or Disclosure:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
The Individual or the Individual’s Representative must read or have the following read to them and initial by each item
below:
_____
I understand that I may inspect or copy the protected health information to be used or disclosed under
(Initials) this authorization. I understand I may refuse to sign the authorization. I understand that the refusal to
sign this authorization may mean that the use and/or disclosure described in this form will not be
allowed.
I understand this Release is valid for one year from today’s date.
_____
(Initials)
_____
I understand that I may revoke this Release at any time by notifying the providing organization in
(Initials) writing. It will not have an effect on actions that were taken prior to the revocation.
_____
I understand that once the uses and disclosures have been made pursuant to this authorization, the
(Initials) information released may be subject to re-disclosure by any recipient and will no longer be
protected by federal privacy laws.
_____
This will not condition treatment or payment on my providing authorization for this use or disclosure
(Initials) except to the extent the provision of health care is solely for the purpose of creating protected health
information for disclosure to a third party.
I certify that I agree to the uses and disclosures listed above and that I have received a copy of this Authorization. (Form
must be completed before signing).
______________________________________________________
_______________________________
Signature
Date
______________________________________________________
________________
_______________________________
Signature of Personal Representative (if applicable)
Date
Description of Authority
Rev. 08/2015

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