Hipaa Compliant Authorization For Disclosure

HIPAA COMPLIANT AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION

Patient:

Name of Patient / Previous Names

Birth Date

________________________________________________

Street Address

City, State, Zip Code

Authorizes:

Release to:

Name of Health Care Provider / Plan / Other

Name of Health Care Provider / Plan / Other

Street Address, City, State, Zip Code

Street Address, City, State, Zip Code

Phone / Fax Number

Phone / Fax Number

Format to be provided:

_______ printed copy _______ electronic copy

Dates of Service: __________ to _________

Information to be released:

**will be provided records produced by Nevada Orthopedic & Spine Center only**

___ Office Visits

___ Procedure Reports

___ Entire Record

___ Billing

___ In Office X-Ray Images ($15.00 charge applied)

___ Laboratory Results

___ Medications

___ Consultations

___ Diagnostic Results

___ Other (Specify): _______________________

Purpose of disclosure:

___________________________________________________________________________________________________

I understand that if the person(s) and/or organization(s) listed above are not health care providers, health plans or health care clearinghouses, which must follow the

federal privacy standards, the health information disclosed as a result of this authorization may no longer be protected by the federal privacy standards and my health

information may be redisclosed without obtaining my authorization.

Your rights with respect to this authorization:

1) I understand this consent may be revoked at any time, with the exception and to the extent that disclosure of this information has already occurred prior to the

receipt of revocation by the above named provider. 2) I understand if written revocation is not received, this authorization will be considered valid for a period of

time not to exceed 12 months from the date signed. To initiate revocation of this authorization, I must submit my request in writing to the “Authorizes” entity above.

3) I understand a photocopy of this authorization is to be considered as valid as the original. 4) I understand the information used or disclosed pursuant to this

authorization may be transmitted electronically and may be subject to re-disclosure by the recipient and may no longer be protected by Federal Law. 5) I understand

that I have the right to refuse to sign this authorization, am signing this authorization voluntarily, and that treatment, payment, enrollment, or eligibility for benefits

may not be conditioned on obtaining the authorization. 6) I have the right to receive a copy of this authorization and any records obtained with its use. 7) I

understand this consent includes disclosure of: Alcohol, Drug Abuse and/or Psychiatric records, Sexually Transmitted Disease and HIV/AIDS information. 8) I have the

right to inspect or copy the health information I have authorized to be used or disclosed by this authorization form. I may arrange to inspect my health information,

or obtain copies of my health information, by contacting the Privacy Officer.

Expiration Date:

This authorization is good until the following date(s)

or for one year from the date signed.

I have had an opportunity to review and understand the content of this authorization form. By signing this authorization, I am confirming that it accurately reflects my

wishes.

______________________________________________ Date

____________

Signature of Patient or Legal Representative:

:

If signed by other than the patient, select authority and provide documentation:

___ Parent of minor child ___ Power of Attorney ___ Representative of Deceased’s Estate ___ Representative of Incapacitated Adult ___ Other

Witness:

Revised 5/4/2015 AST; Revised 12/24/2015 AST