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)
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 ___/___/______
□ 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).
□ 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