Authorization For Disclosure Of Protected Health Information printable pdf download

Authorization For Disclosure Of Protected Health Information

Authorization for Disclosure of Protected Health Information

[Sample form developed by Health Law Advocates, Inc. Bracketed sections

added by Health Assistance Partnership.]

I, ________________, authorize the disclosure of my protected health information

as described herein. I

understand that this authorization is voluntary and made to confirm my direction. I understand that, if the

person(s) or organization(s) that I authorize to receive my protected health information are not subject to

federal and state health information privacy laws,

subsequent disclosure by such person(s) or

organization(s) may not be protected by those laws.

1. I authorize the following person(s) and/or organization(s) to disclose my protected health information (as

specified below):

Name(s) ______________________________

Organization(s)

Address

2. I authorize the following person(s) and/or organization(s) to receive my protected health information, as

disclosed by the person(s) and/or organization(s) above.

Name(s)

Organization(s)

Address

3. Specific description of the protected health information that I authorize for disclosure (authorization to

disclose psychotherapy notes must be separate):

4. Specific description of the purpose for each use or disclosure (or write “At the request of the individual”

in this space):

5. I understand that I may revoke this authorization in writing at any time [by sending a signed and dated

written statement to (name of person or organization and address) saying that I am revoking my

authorization to disclose health records,] except to the extent that the person(s) and/or organization(s)

named above have taken action in reliance on this authorization. [NOTE: If the organization is a covered

entity under HIPAA, add: I further understand that my eligibility for health benefits, my enrollment in a

health plan, and my treatment will not be affected by whether or not I sign this authorization.]

Authorization For Disclosure Of Protected Health Information