Hipaa Privacy Authorization Form Page 2

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HIPAA Privacy Authorization Form
Authorization for Use or Disclosure of Protected Health Information
(Required by the Health Insurance Portability and Accountability Act – 45 CFR Parts 160 and 164)
1.
I hereby authorize
to use and/or disclose the
[Name of Health Care Provider]
protected health information described below to
.
[Name of Individual]
2.
Authorization for Release of Information. Covering the period of health care from
□
□
______________ to ______________
OR
all past, present and future periods:
□
a.
I hereby authorize the release of my complete health record (including records relating
to mental health care, communicable diseases, HIV or AIDS, and treatment of
alcohol/drug abuse).
OR
□
b.
I hereby authorize the release of my complete health record with the exception of the
following information:
□
Mental health records
□
Communicable diseases (including HIV and AIDS)
□
Alcohol/drug abuse treatment
□
Other (please specify): _______________________________________________
3.
This medical information may be used by the person I authorize to receive this information for
medical treatment or consultation, billing or claims payment, or other purposes as I may direct.
4.
This authorization shall be in force and effect until
, at which time this
authorization expires.
[Date or Event]
5.
I understand that I have the right to revoke this authorization, in writing, at any time. I
understand that a revocation is not effective to the extent that any person or entity has already acted in
reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance
coverage and the insurer has a legal right to contest a claim.
6.
I understand that my treatment, payment, enrollment or eligibility for benefits will not be
conditioned on whether I sign this authorization.
7.
I understand that information used or disclosed pursuant to this authorization may be disclosed
by the recipient and may no longer be protected by federal or state law.
Signature of Patient or Personal Representative
Date
Print Name of Patient or Personal Representative
Relationship to Patient
687955.03

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