Pebtf Hipaa Form 1 - Authorization To Release Protected Health Information (Page 2 of 4) in pdf

Duration of Authorization (check only one)



This Authorization will remain in effect until revoked in writing, pursuant to the

procedure set forth below.



This Authorization will expire on:___________________________(insert date)



This Authorization will expire upon the following event:___________________

(insert occurrence or life event).



This Authorization will expire upon the date the individual’s coverage for PEBTF

benefits ends.



This Authorization will expire six months after the date the individual’s coverage for

PEBTF benefits ends.

I understand that I have the right to revoke this authorization earlier than the date/event set forth

above. I understand that any revocation must be in writing and must include my name, address, telephone

number, date of this authorization and my signature and that I should send the revocation to:

PENNSYLVANIA EMPLOYEES BENEFIT TRUST FUND

ATTN: PRIVACY OFFICER

150 S. 43

STREET, SUITE 1

HARRISBURG, PA 17111-5700

I understand that a revocation is not effective to the extent that PEBTF has already released

information pursuant to this Authorization and the parties named in this Authorization have relied on the

use or disclosure of the protected health information prior to the receipt of the revocation.

I understand that the terms of this Authorization are governed by the Health Insurance Portability

and Accountability Act of 1996, and its implementing regulations (“HIPAA”). I understand that the

PEBTF generally may not condition payment, enrollment or eligibility for benefits on my execution of

this authorization. The law permits the PEBTF to condition enrollment in a health plan or eligibility for

benefits on provision of an authorization requested prior to my enrollment in the health plan if:

1. The authorization is sought for the health plan’s eligibility or enrollment determinations

relating to me or its underwriting or risk rating determinations; and

2. The authorization is not for a use or disclosure of psychotherapy notes.

I understand that the information used or disclosed pursuant to this Authorization may be subject

to re-disclosure by the Recipient and, in that case, will no longer be protected by HIPAA.

I have read and considered the contents of this Authorization and I confirm that this form is

consistent with my directions.

__________________________________________

Signature of Individual or Personal Representative

__________________________________________

Description of Personal Representative’s Authority

__________________________________________

Date of Authorization

Auth 1(au)

Rev. 9/23/2013

Pebtf Hipaa Form 1 - Authorization To Release Protected Health Information Page 2

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