Fillable Hippa Authorization Form printable pdf download

HIPAA AUTHORIZATION FORM

Applicant’s Full Name

Applicant’s Social Security Number

Applicant’s Date of Birth

Address

Applicant’s Telephone Number

City, State Zip Code

I hereby authorize use or disclosure of protected health information about me as described below.

The following specific person/class of person/facility is authorized to use or disclose information about me:

_______________________________________________________________________________________________________________

The following person (or class of persons) may receive disclosure of protected health information about me:

The Hope Foundation Physician Advisory Board

The specific information that should be disclosed is:

____________________________________________________________________________________________________________

UNLESS YOU SIGN HERE, NO INFORMATION ABOUT ALCOHOL/SUBSTANCE ABUSE, HIV/AIDS, OR MENTAL HEALTH

WILL BE DISCLOSED:

YES, DISCLOSE THIS INFORMATION *______________________

NO, DO NOT DISCLOSE THIS INFORMATION * ______________________

I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it,

and would then no longer be protected by federal privacy regulations.

I may revoke this authorization by notifying The Hope Foundation in writing of my desire to revoke it. However, I understand that any

action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

My purpose/use of the information is for the application process of The Hope Foundation.

This authorization expires on _____________, 200___, OR upon occurrence of the following event that relates to me or to the purpose of

the intended use or disclosure of information about me: _____________________________________.

THIS FORM MUST BE FULLY COMPLETED BEFORE SIGNING – note that signature is required in two places.*

___________________________________________

_______________________________

___________________________________

Date of Individual’s Signature

Signature of Individual*

Date of Birth or

(The person about whom the information relates)

Social Security Number

OR, if applicable –

_______________________________________

_______________________________

___________________________________

Date of Guardian’s/Personal

Signature of Guardian

Description of Authority to Act

Representative’s Signature

for the Individual

A copy of this completed, signed and dated form must be given to the Individual or other signator.

Official Use Only

Received

Processed By

Log #

Hippa Authorization Form

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