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HIPAA Privacy Authorization Form

Authorization for Use or Disclosure of Protected Health Information

(Required by the Health Insurance Portability and Accountability At, 45 C.F.R. Parts 160 and 164)

1. Authorization

I authorize Family Medical Centers of Tampa Bay, Inc (healthcare provider) to use and disclose the

protected health information described below to _______________________________ (individual

seeking the information).

2. Effective Period

This authorization for release of information covers the period of healthcare from:

□ ___/___/______ to ___/___/______

***OR***

□ all past, present, and future periods

3. Extent of Authorization

□ I authorize the release of my complete health record (including records relating to mental healthcare,

communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse).

***OR***

□ I authorize the release of my complete health record with the exception of the following information:

□ Mental Health Records

□ Communicable diseases (including HIV and AIDS)

□ Alcohol/drug abuse treatment

□ Other (please specify) _________________________________________________________

4. This medical information may be used by the person I authorize to receive this information for

medical treatment or consultation, billing or claims payment, or other purposes as I may direct.

5. This authorization shall be in force and effect until ______________________________ (date or

event), at which time this authorization expires.

6. I understand that I have the right to revoke this authorization, in writing, at any time. I understand

that a revocation is not effective to the extent that any person or entity has already acted in reliance

on my authorization or if my authorization was obtained as a condition of obtaining insurance

coverage and the insurer has a legal right to contest a claim.

7. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be

conditioned on whether I sign this authorization.

8. I understand that information used or disclosed pursuant to this authorization may be disclosed by

the recipient and may no longer be protected by federal or state law.

________________________________________________________________________

Signature of patient or personal representative

________________________________________________________________________

Printed name of patient or personal representative and his or her relationship to patient

______________________________

Date of signature

Hipaa Privacy Authorization Form - Authorization For Use Or Disclosure Of Protected Health Information