Authorization For Release Of Protected Health Information Under Federal Health Insurance Portability And Accountability Act Of 1996 (Hippa) printable pdf download

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION

UNDER FEDERAL HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996

(HIPPA)

I hereby authorize the use or disclosure of my individually identifiable health information as described below.

I understand that this authorization is voluntary. I understand that if the organization authorized to receive the

information is not a health plan or health care provider, the released information may be subject to re-disclosure

and may no longer be protected by federal privacy regulations, including HIPAA. I hereby release the

organization providing this information from any legal responsibility or liability for disclosure of this information

to the extent indicated and authorized herein.

Patient Name:_____________________________________________ ID/SS #: _________________________

Patient Address: _________________________________________________ Date of Birth: _____/____/____

(Street/City/State/Zip)

Persons/organizations providing the information: _______________________________________________

(Medical Provider Name/VA Hospital or Clinic)

Persons/organizations receiving the information: (Send to)

North Carolina Heroes Fund

PO Box 652, Pineville, NC 28134

Fax: 980-225-0395

email:

Specific description of information, covering health care from to___________________________________:

(Start Date)

(End Date)

Complete health records and bills (prescription bills, history and physical, discharge summary, operative reports,

consultation reports, radiology and imaging reports), excluding all images (x-rays, photographs, etc.)

Other (please specify) _____________________________________________________________________

The patient or the patient’s representative must read and initial the following statements:

1. I understand that this authorization will expire on six month after date of signing this form.

Initials: ________

2. I understand that I may revoke this authorization at any time by notifying the providing organization in writing and

that, if I do revoke this authorization, this will not have any effect on any action the providing organization takes

before receiving the revocation.

Initials:___________

3. I understand that I have the right to refuse to sign this Authorization.

Initials:

4. I understand that information disclosed pursuant to this Authorization may be subject to redisclosure by

a recipient of such information. It is possible that once disclosed, the privacy of the information will no

longer be protected under federal medical privacy law. Initials: ___________

5. I understand the data release may include material protected by law including Mental Health, Drugs and

Alcohol, HIV/AIDS and other communicable diseases and Genetic Testing. Initials:___________

I have read and understand the

information in this Authorization.

_________________________________________________ Date: __________________________

Signature of patient or designated representative

(Form MUST be completed before signing).

YOU MAY REFUSE TO SIGN THIS AUTHORIZATION

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Authorization For Release Of Protected Health Information Under Federal Health Insurance Portability And Accountability Act Of 1996 (Hippa)

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