Authorization Form For Use/disclosure Of Protected Health Information

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AUTHORIZATION FOR USE OR DISCLOSURE OF
PROTECTED HEALTH INFORMATION
(Page 1 of 2)
1.
Client’s name: ______________________________________________________
First Name
Middle Name
Last Name
2.
Date of Birth: ___/___/___
3.
Date authorization initiated: ___/___/___
4.
Authorization initiated by:
______________________________________________________________________
Name (client, provider, or other)
5.
Information to be released:
Authorization for Psychotherapy Notes ONLY (Important: If this authorization is for
Psychotherapy Notes, you must not use it as an authorization for any other type of
protected health information.)
Other (describe information in detail):
______________________________________________________________________
6.
Purpose of Disclosure: The reason I am authorizing release is:
My request
Other (describe):
______________________________________________________________________
7.
Person(s) Authorized to Make the Disclosure:
______________________________________________________________________
8.
Person(s) Authorized to Receive the Disclosure:
______________________________________________________________________
9.
This Authorization will expire on ___/___/___ or upon the happening of the following event:
______________________________________________________________________
Authorization and Signature: I authorize the release of my confidential protected health
information, as described in my directions above. I understand that this authorization is voluntary,
that the information to be disclosed is protected by law, and the use/disclosure is to be made to
conform to my directions. The information that is used and/or disclosed pursuant to this
authorization may be re-disclosed by the recipient unless the recipient is covered by state laws
that limit the use and/or disclosure of my confidential protected health information.
Signature of the Patient:
_________________________________________________________________
Signature of Personal Representative:
_________________________________________________________________
Relationship to Patient if Personal Representative:
___________________________________________
Date of signature: ___________________________

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