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

Pebtf Hipaa Form 1 - Authorization To Release Protected Health Information Page 4

7. “Description of Personal Representative’s Authority” means a description of the authority

by which a personal representative signs the authorization instead of the individual who

is the subject of the protected health information. For example, if a parent is signing on

behalf of a minor child, the description of the authority would read, “parent”.

8. “Date of Authorization” is the date that the authorization is granted, usually the date of

the signature.

Auth 1(au)

Rev. 9/23/2013

Pebtf Hipaa Form 1 - Authorization To Release Protected Health Information Page 4