Authorization For Release Of Health Information Pursuant To Hipaa printable pdf download

Authorization for Release of Health Information Pursuant to HIPAA

Patient Name

Date of Birth

Social Security Number

Patient Address

I, or my authorized representative, request that health information regarding care and treatment of the patient as set forth

in this form, in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) be disclosed,

orally or in writing to the physician listed below. I understand that:

1. I have the right to refuse to sign this authorization, and my signature is voluntary.

2. I have the right to revoke this authorization by sending written notification to the health provider named herein, but

such revocation shall not be effective to the extent that action has already been taken based on this authorization.

3. Information disclosed pursuant to this authorization may be disclosed to others by the attorney(s) for legal purposes

and may no longer be protected from disclosure to others by Federal or State law.

4. I have a right to determine a date or event at which time this authorization expires, or I may designate NONE, in

which event this authorization has no expiration date.

5. This authorization permits the release of information relating to treatment for alcohol and drug abuse, mental health

treatment, and confidential HIV related information, or as noted below.

6. This authorization does not authorize you to discuss my health information or medical care with anyone other than the

physician(s) listed below.

7. Name and address of health provider or entity to release this information:

8. Name and address of person(s) to whom this information will be sent:

9(a). Specific information to be released: Entire medical record, including progress notes, consults, correspondence,

billing, pathology reports, lab reports, operative reports, radiology reports, radiology films, ER reports, discharge

summaries, histories and physical exams, psychological tests, and any other materials in the provider’s possession

concerning this patient. (Cross out and initial any you do not want released)

10. Reason for release of information:

11. Date or event on which this authorization will expire:

At request of individual.

All items on this form have been completed and my questions about this form have been answered. In addition, I have

been provided a copy of the form.

______________________________________________

Date: __________________________________

Signature of Patient

Authorization For Release Of Health Information Pursuant To Hipaa