Form 009893 - Hipaa - Patient Acknowledgement Form Page 2

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Authorization for Release of Information
HIPAA - Patient Acknowledgement Form
Name of Patient ____________________________________
Date of Birth _______________
I understand that, under the Health Insurance Portability & Accountability Act of 1996
(HIPAA), I have certain rights to privacy regarding my protected health information. I
_________________________________________ is authorized to release protected health
understand that this information can and will be used, but is not mandatory for me to sign
information about the above named patient to the entities named below. The purpose is to
in order to:
inform the patient or others in keeping with the patient’s instructions.
• Conduct, plan, and direct my treatment and follow-up among the multiple
Entity to Receive Information.
Description of information to be released.
healthcare providers who may be involved in that treatment directly and indirectly
Check each person/entity that you approve to
Check each that can be given to person/entity
• Obtain payment from third party payers
receive information.
on the left in the same section.
• Conduct normal healthcare operations such as quality assessments and physician
Results of lab tests/x-rays
certifications
Voicemail
Other _____________________________
I have been informed by you of your Notice of Privacy Practices containing a more
Financial
complete description of the uses and disclosures of my health information. I have been
Spouse
Medical as follows __________________
given a copy of your Notice of Privacy Practices prior to signing this consent. I
understand that this office has the right to change its Notice of Privacy Practices from
Financial
time to time and that I may contact this office at any time at the address above to obtain a
Parent (provide name)
Medical as follows __________________
current copy of the Notice of Privacy Practices.
Financial
I understand that I may request in writing that you restrict how my private information is
used or disclosed to carry out, payment or health care operations. I also understand you
Other (provide name)
Medical as follows __________________
are not required to agree to my requested restrictions, but if you do agree then you are
bound to abide by such restrictions.
Patient Information
I understand that I may revoke this consent in writing at any time, except to the extent
that you have taken action relying on this consent.
I understand that I have the right to revoke this authorization at any time, and that I have the right
to inspect or copy the protected health information to be disclosed as described in this document.
I understand that revocation is not effective in cases where the information has already been
Patient Name:
__________________________________________
disclosed but will be effective going forward.
Signature:
I understand that information used or disclosed as a result of this authorization may be subject to
__________________________________________
redisclosure by the recipient and may no longer be protected by federal or state law.
Relationship to Patient: _____________________________________
I understand that I have the right to refuse to sign this authorization and that my treatment will not
be conditioned on signing. This authorization shall be in effect until revoked by the patient.
Date:
___________________________________________
_________________________________________________________
________________
Signature of Patient or Personal Representative
Date
Description of Personal Representative’s Authority (attach necessary documentation):
____________________________________________________________________
FORM 009893
N/06/12
ITEM 40686
WAINRIGHT WASSEL PATTERSON OFFICE SUPPLIES 800.637.1140

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