Hipaa Release And Authorization Page 2
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3In determining whether I am incapacitated, all individually identifiable health information and medical
records shall be released to my agent, including any written opinion relating to my incapacity that my agent may
have requested. This release authority applies to any information governed by HIPAA and applies even if my agent
has not yet begun serving as my agent.
The authority given to my agent shall supersede any prior agreement that I may have made with my health-
care providers to restrict access to or disclosure of my individually identifiable health information. The individually
identifiable health information and other medical records given disclosed, or released to my agent may be subject to
re-disclosure by my agent and may no longer be protected by HIPAA.
TERMINATION
This Release shall terminate on the first to occur of: (1) two years following my death, or (2) upon my
written revocation actually received by the covered entity. Proof of receipt of my written revocation may be by
certified mail, registered mail, facsimile, electronic mail, or any other receipt evidencing actual receipt by the
covered entity. This Release shall not be affected by my subsequent disability or incapacity. There are no
exceptions to my right to revoke this Release.
RELEASE
Each covered entity that acts in reliance on this Release shall be released from liability which may result
from disclosing my individually identifiable health information and other medical records.
LEGAL ACTION
I authorize my agent to bring a legal action against a covered entity which refuses to accept and recognize
this Release. Further, in order to fulfill my intent as expressed herein, I authorize my agent to sign any
documentation that my agent deems necessary or appropriate in order to secure the disclosure of my individually
identifiable health information and other medical records.
SUBSEQUENT DISCLOSURE OF INFORMATION
Any information disclosed to my agent pursuant to this Release may subsequently be disclosed to another
party by my agent. My agent shall not be required to indemnify a covered entity or perform any act in the event
information is subsequently disclosed by my agent.
COPIES AND FACSIMILES
Copies or facsimiles of this Release shall be as valid as the original Release.
I sign my name to this Release on _______________, 20__, at __________ County, State of __________.
Principal
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