Authorization For The Release Or Use Of Protected Health Information (Phi) printable pdf download

Authorization for the Release or Use of

(County Department of Job and Family

Protected Health Information (PHI)

Services Letterhead)

Name:

Address:

Billing Number:

Social Security Number:

(Optional--see reverse side)

I, ________________________________, hereby authorize __________________________________ to disclose protected

(Name of individual)

(Name of covered entity, such as “ODJFS”)

health information to _______________________________ for the purpose of _____________________________________

(Who will receive the information?)

_____________________________________________________________________________________________________________________________

(Describe why this information is being released)

Information is

to be mailed to: Street

City

State

Zip Code

Is this information being released for an insurance claim?

_____ NO

_____ YES (If YES, see Section II on reverse side.)

SECTION B:

The specific protected health information to be released is: ____________________________________________________

___________________________________________________________________________________________________

(What information should be released?)

SECTION C:

By signing below, I understand that:

This authorization shall expire on _________________________ or until revoked by me in writing, whichever comes first.

(Date or completion of “event”)

I have the right to revoke or cancel this authorization at any time by providing notice in writing to:

(insert CDJFS address)

If I revoke or cancel this authorization, it is not effective for the use or for the disclosure of my protected health information

that has already occurred.

Any information used or disclosed as per this specific authorization may be re-disclosed by the person or entity

receiving the information. In such a situation, it may no longer be protected by federal or state law.

I am not required to sign this authorization. If I refuse to sign this form, it will not affect my Medicaid eligibility, my

eligibility for other programs such as Disability Assistance Medical, Refugee Medical, or Healthy Start Healthy Families

or my application for such programs.

I have a right to inspect or copy the protected health information that will be used or disclosed as per this authorization.

If by law we cannot send the protected health information to the entity listed above, please initial in the following space if

you want a copy of the information sent to you directly:__________.

SECTION D:

Signature of Individual or Authorized Representative

Print name of individual

Representative’s legal authority to individual

Print name of Authorized Representative

Today's Date:

*** Important information and instructions for completing this form are on the reverse side.***

Authorization For The Release Or Use Of Protected Health Information (Phi)

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