Authorization To Use And/or Disclose Personal Health Plan printable pdf download

Authorization To Use And/or Disclose Personal Health Plan

Instructions for the Individual Completing this Authorization Form

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The group health plan (“Plan”) sponsored by Loyola Marymount University cannot use or disclose

your health information (or the health information of your children or other people on whose behalf

you can act) for certain purposes without your Authorization. This form is intended to meet the

Authorization requirement.

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You must respond to each section, and sign and date this form, in order for the Authorization to be

valid.

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If you wish to authorize the use and/or disclosure of any notes the Plan may have that were taken by

a mental health professional at a counseling session, along with other health information, you must

complete one (1) form for the counseling session notes and one (1) separate form for other health

information.

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The sample responses given for each section below are not exhaustive and are meant for

illustrations only. Under HIPAA, there are no limitations on the information that can be authorized

for disclosure.

Section A: Health Information to be Used or Released. Describe in a specific and meaningful way

the information to be used or released. Example descriptions include medical records relating to my

appendectomy, my laboratory results and medical records from [date] to [date], or the results of the

MRI performed on me in July 1998.

Section B: Person(s) Authorized to Use and/or Receive Information. Provide a name or specific

identification of the person, class of persons, or organization(s) authorized to use or receive the health

information described in Section A.

Section C: Purpose(s) for which Information will be Used or Released. Describe each purpose for

which the information will be used or released. If you initiate the Authorization and do not wish to

provide a statement of purpose, you may select “at my request.”

Section D: Expiration. Specify when this Authorization will expire. For example, you may state a

specific date, a specific period of time following the date you signed this Authorization Form, or the

resolution of the dispute for which you’ve requested assistance.

Signature Line. If you are authorizing the release of somebody else’s health information, then you must

describe your authority to act for the Individual.

Authorization To Use And/or Disclose Personal Health Plan