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HIPAA Privacy Authorization Form

Authorization for Use or Disclosure of Protected Health Information

(Required by the Health Insurance Portability and Accountability Act ---- - 45 CFR Parts 160 and 164)

1. I hereby authorize all medical service sources and health care providers to use and/or disclose the

protected health information (‘‘PHI’’) described below to my agent identified in my durable power of attorney

for health care named __________________________________________________________________.

2. Authorization for release of PHI covering the period of health care (check one)

from (date) _________________ - to (date)_______________________ OR

all past, present and future periods.

3. I hereby authorize the release of PHI as follows (check one):

my complete health record (including records relating to mental health care,

communicable diseases, HIV or AIDS, and treatment of alcohol/drug abuse). OR

my complete health record with the exception of the following information

(check as appropriate):

Mental health records

Communicable diseases (including HIV and AIDS)

Alcohol/drug abuse treatment

Other (please specify): ________________________________________________ .

4. In addition to the authorization for release of my PHI described in paragraphs 3 a and 3 b of this

Authorization, I authorize disclosure of information regarding my billing, condition, treatment and prognosis to

the following individual(s):

Name ____________________________________________ Relationship _____________________

5. This medical information may be used by the persons I authorize to receive this information for medical

treatment or consultation, billing or claims payment, or other purposes as I may direct.

6. This authorization shall be in force and effect until nine (9) months after my death or

__________________________________, (date or event) at which time this authorization expires.

7. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a

revocation is not effective to the extent that any person or entity has already acted in reliance on my

authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer

has a legal right to contest a claim.

8. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned

on whether I sign this authorization.

9. I understand that information used or disclosed pursuant to this authorization may be disclosed by the

recipient and may no longer be protected by federal or state law.

_____________________________________________________

Date: _________________________

Signature of Patient

eep original, and give copies to your health care provider, agent and family members

Hipaa Privacy Authorization Form