Hipaa Medical Authorization Form

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HIPAA MEDICAL AUTHORIZATION FORM
I, ________________________, hereby authorize _________________________________________
(Name of Parent/Guardian))
(Physician or Other Medical Provider)
to use and/or disclose the protected health information described below pertaining to _____________
__________________________________________________to the Coweta County School System.
(Name of Child)
The protected health information will be used or disclosed upon request for the following purposes
[please name and explain each purpose]:_________________________________________________
This authorization for use and/or disclosure applies to the information described below [mark those
that apply]:

Any and all records in the possession of __________________________________________,
[Physician or Other Medical Provider]
including mental health, HIV, and/or substance abuse records. [Cross out any item you do
not authorize to be released.]

Records
regarding
treatment
for
the
following
condition
of
injury:
_________________________________________ on or about _______________________.

Records covering the period of time ________________________ to __________________.

Other [please specify – include dates] ____________________________________________.
I understand that I have the right to revoke this authorization, in writing, at any time by sending such
written notification to _______________________________________________________________.
[Physician or Other Medical Provider]
I also understand that my revocation is not effective to the extent that the persons I have authorized to
use and/or disclose my protected health information have acted in reliance upon this authorization.
I understand that I do not have to sign this authorization and that ______________________________
[Physician or Other Medical Provider]
may not condition treatment or payment on whether I sign this authorization.
I understand that information used or disclosed pursuant to this authorization may be subject to
disclosure by the recipient and no longer protected by federal laws and regulations regarding the
privacy of my protected health information.
This authorization expires on [please list a specific date or event]:_____________________________.
I certify that I have received a copy of this authorization.
__________________________________________
Date:_____________________________
Signature of Parent or Guardian
__________________________________________
Name of Parent or Guardian
__________________________________________
Description of Guardian’s Authority (if applicable)

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