Form Hipaa-12 - Authorization Form For Release Of Health Information (Page 2 of 3) in pdf

Form Hipaa-12 - Authorization Form For Release Of Health Information Page 2

AUTHORIZATION FORM FOR RELEASE OF HEALTH INFORMATION



Other: _________________________________

____________________

** OR MARK one of the below two options for entire medical record:



1- Entire Medical Record Including HIV related information (excluding HIV test results), Mental health (including

psychotherapy notes), and Substance abuse (including alcohol/drug abuse)



2- Entire Medical Record NOT Including HIV related information or test results, Mental health (including

psychotherapy notes), and Substance abuse (including alcohol/drug abuse)

This Authorization is made for the following purpose:



At my request, OR



Specify: ____________________________________________________________

HIV Test Results

I specifically authorize the release of my HIV test results by ______________________ to __________________ at the contact

information mentioned above. ___________

Initials

This Authorization is made for the following purpose:



At my request, OR



Specify: ____________________________________________________________

I understand that I am only authorizing the disclosure of my HIV test results in this specific instance.

No information about my test results will be released in the future to any party without an additional signed authorization.

________________________________________

________________________

SIGNATURE OF PATIENT

DATE

CONDITIONS OF AUTHORIZATION

1. This Authorization will expire within one year of original signature and date, unless

otherwise indicated (insert date): ____________________________________

2. I may revoke this Authorization at any time by notifying Planned Parenthood in writing, and it will be effective on the

date notified except to the extent that Planned Parenthood has already acted upon such Authorization.

3. I understand that health information used or disclosed pursuant to this Authorization may not be further used or

disclosed by the recipient unless another authorization is obtained from me or unless such use or disclosure is specifically

required or permitted by law.

HIPAA-12 (9/1/16)

Form Hipaa-12 - Authorization Form For Release Of Health Information Page 2