Authorization For Release Of Protected Health Information printable pdf download

Authorization for Release of Protected Health Information

I, ____________, hereby appoint [AHD name] as my Personal Representative

for health care disclosure under the Standards for Privacy of Individually Identifiable

Health Care Information (45 CFR Parts 160 and 164) under the Health Insurance

Portability and Accountability Act of 1996 (HIPAA) and under the California

Confidentiality of Medical Information Act (CMIA). (In the event that the aforementioned

person cannot act for any reason, I hereby appoint [Alt name] as my Personal

Representative. In the event that both the aforementioned persons cannot act for any

reason, I hereby appoint [Alt Name 2] as my Personal Representative.)

My Personal Representative shall have the same access to my health and

medical information as I would.

The authority granted to my Personal Representative herein shall be effective

immediately and shall not be dependent on a determination of whether or not I lack

capacity.

I authorize the disclosure of all of my health and medical information, whether

now existing or hereafter created, related to my physical or mental ability to (a) perform

the duties of a trustee of a trust or administer a trust, (b) understand or be able to make

or communicate decisions about my property or financial or business affairs or the

financial or business affairs of any other person for whom I am an agent under a

durable power of attorney, or (c) make informed health care decisions regarding myself

or any other person for whom I am an agent under an advance health care directive or

similar instrument.

This authorization shall apply to any health care providers, including physicians,

nurses, and all other persons, entities, who may have provided, or are providing at the

time such health or medical information is sought by my Personal Representative, any

type of health or medical care to me.

Such health and medical information shall be provided to: (1) my __

[spouse/domestic partner]__ ; (2) my lineal ancestors and descendants; (3) my

Personal Representative; (4) my and my Personal Representative's respective

attorneys; and (5) any court or other governmental agency which may require such

information in connection with any proceeding before such court or governmental

agency.

My Personal Representative may disclose my health and medical information to

such other persons or entities, such as trustees of trusts of which I am or have been a

trustee, or agents under durable powers of attorney or advance health care directives

executed by me, as my Personal Representative may determine in my Personal

Representative's sole and absolute discretion.

Although information disclosed by a health care provider pursuant to this

authorization is subject to redisclosure and may no longer be protected by the privacy

Authorization For Release Of Protected Health Information