Hipaa Authorizaton / Roi For Use/disclosure Request For Protected Health Information printable pdf download

HIPAA AUTHORIZATON / ROI for Use/Disclosure

Request for Protected Health Information

Patient Information

Clinician/Entity to Disclose Information/Materials To (RECIPIENT)

Last Name

First Name

Middle Initial

Date of Birth

Last Name

First Name

Middle Initial

Title

Address

Facility Name and Address

Telephone #

Email Address

Telephone #

Fax #

Email Address

MATERIAL RECEIPT/CUSTODIAN Acknowledgement-ONLY IF MATERIALS ARE TRANSFERRED

In the event that materials are received (DNA tubes, tissue blocks or slides, Original sample, etc.) as listed in the section below, I hereby acknowledge that I am retaining

full custodian responsibilities of said materials and acknowledge that Ambry Genetics is no longer in possession of stated materials. Any further requests for the listed

materials will be forwarded to me or my facility for response.

DNA Tube ID: Sample ID: ______________________________________

Number of Tubes/Containers: ___________________________

All materials relinquished (i.e. Ambry Genetics retains no further material)?

YES

Name of RECIPIENT Signatory: ________________________________

* Signed: ___________________________ Dated: _________________

Patient/Representative Disclaimer

Patient / Personal Representative Authorization & Approval

As required by the Health Information Portability and Accountability Act

I hereby authorize this Clinical Laboratory to use and disclose health information or

of 1996 (HIPAA) and California law, this Clinical Laboratory may not

requested materials concerning the above listed Patient to the stated RECIPIENT.

use or disclose your individually identifiable health information except as

Health information/materials to be used or disclosed: *

provided in our Notice of Privacy Practices without your authorization.

PLEASE CHECK ONE AND NOTE EXCEPTIONS:

Your completion of this form means that you are giving permission for

the uses and disclosure described below. Please review and complete this

Sample related materials (ex. DNA, tissue, slides)

form carefully. It may be invalid if not fully completed. You may wish to

Any and all health information or materials may be released, including, but

ask the person or entity you want to receive your information to complete

not limited to, drug and/or alcohol abuse records and/or HIV test results, if

the sections detailing the information to be released and the purposes for

any, except as specifically provided below:

the disclosure.

________________________________________________________________________

I understand that I may revoke this authorization at any time notifying

The information/materials may be used only for the following purposes:

this Clinical Laboratory in writing. My revocation will not affect actions

At the request of the individual or their personal representative

taken by this Clinical Laboratory prior to its receipt. I understand that

although federal law does not protect health information which is

disclosed to someone other than another health care provider, health plan

Effect of Refusal to Sign Authorization

or health care clearinghouse, under California law all recipients of health

I understand that my clinical laboratory testing services or benefits will not be affected

care information are prohibited from re-disclosing it except as specifically

whether I sign or do not sign this form. This authorization is effective now and will

required or permitted by law.

remain in effect until:

____________________________________

If I have any questions about this authorization, I may contact client

(Expiration event or date; can be indefinite)

services or Ambry Genetics Privacy Officer at Ambry Genetics at 866-262-

I understand that I have the right to receive a copy of this authorization.

7943, who will provide me with more information about this authorization,

If not signed by the patient, please indicate relationship:

or about privacy issues. I may be provided a copy of the completed

Parent or guardian of minor patient (to the extent minor could not have consented to

Authorization to Release Information form upon request.

the care)

Guardian or conservator of an incompetent patient

Beneficiary or personal representative of deceased patient **

•

If personal representative of a deceased patient, please provide one of the

following (or similar):

Clinical Laboratory

Copy of Power of Attorney

* For the release of records (1) protected by the Lanterman-Petris-Short

Act (LPS) or (2) containing HIV test results, a separate authorization is

Advanced Directive

Spouse or person financially responsible (where information solely for purpose of

required for each separate disclosure. Further, the LPS Act often requires

that both the patient’s treating physician and the patient sign the

processing application for dependent healthcare coverage)

authorization form before information may be released.

NOTE : PLEASE PROVIDE A COPY OF SIGNATORS DRIVERS LICENSE FOR

** It is unclear whether the beneficiary or personal representative of a

VERIFICATION PURPOSES:

deceased patient can obtain and disclose certain records containing HIV

test results.

Name of Signatory: _____________________________________

* Signed: ___________________________ Dated: ____________

PLEASE FAX THIS FORM TO AMBRY GENETICS UPON COMPLETION at 949-900-5501

Page 1 of 2

Ambry Genetics I 15 Argonaut I Aliso Viejo, California 92656 I USA I Ph: 949-900-5500 I 866-262-7943 I Fax: 949-900-5501; Privacy Officer: Gretchen Enright

Hipaa Authorizaton / Roi For Use/disclosure Request For Protected Health Information

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