Hipaa Release And Authorization
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3HIPAA RELEASE AND AUTHORIZATION
I, ______________________________________________ (Principal), hereby authorize the following
person to act as my agent with regard to the matters specified in this Release:
Name:
__________________________________________
Address:
__________________________________________
Phone:
__________________________________________
If the person designated as my agent is unable or unwilling to serve, I designate the following persons as
my agent hereunder, who shall serve in the following order:
A.
First Alternate Agent
Name:
__________________________________________
Address:
__________________________________________
Phone:
__________________________________________
B.
Second Alternate Agent
Name:
__________________________________________
Address:
__________________________________________
Phone:
__________________________________________
This Release and all of the provisions contained herein are effective immediately. I intend for my agent to
be treated as I would be treated with respect to my rights regarding the use and disclosure of my individually
identifiable health information and other medical records. This Release authority applies to any information
governed by the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), 42 USC 1320d and 45
CFR 160-164.
AUTHORIZATION
I hereby authorize any doctor, physician, medical specialist, psychiatrist, chiropractor, health-care
professional, dentist, optometrist, health plan, hospital, hospice, clinic, laboratory, pharmacy or pharmacy benefit
manager, medical facility, pathologist, or other provider of medical or mental health care, as well as any insurance
company and the Medical Information Bureau Inc. or other health-care clearinghouse that has paid for or is seeking
payment from me for such services (referred to herein as a "covered entity"), to give, disclose and release to my
agent who is named herein and who is currently serving as such, without restriction, all of my individually
identifiable health information and medical records regarding any past, present or future medical or mental health
condition, including all information relating to the diagnosis and treatment of HIV/AIDS, sexually transmitted
diseases, mental illness, and drug or alcohol abuse. Additionally, this disclosure shall include the ability to ask
questions and discuss this protected medical information with the person or entity who has possession of the
protected medical information even if I am fully competent to ask questions and discuss this matter at the time. It is
my intention to give a full authorization to any protected medical information to my agent.
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