HIPAA COMPLIANT AUTHORIZATION
Patient name: ___________________________________________ Date of Birth: _______________
Previous name: __________________________________________
You may use or disclose the following health care information (check all that apply):
All health care information in my medical record
Health care information in my medical record relating to the following treatment or condition:
Health care information in my medical record for the dates(s): ___________________________
Other (e.g., x rays, bills), specify date(s): ___________________________________________
You may use or disclose the following health care information regarding testing, diagnosis, and
treatment, should it be found in my records, only if checked below:
HIV (AIDS virus)
Sexually transmitted diseases
Psychiatric disorders/mental health
Drug and/or alcohol use
You may disclose this health care information to:
Name (or title) and organization or category of persons (i.e. all treating physicians, etc.): _________
Address (optional): ____________________ City: _________________ State: ___ Zip: ________
Reason(s) for this authorization (check all that apply):
At my request
Other (specify) __________________________________________
This authorization ends:
On (date): __________________
When the following event occurs: _________________________________________________
In 90 days from the date signed (if disclosure is to a financial institution or an employer of the patient
for purposes other than payment)
II. My Rights
I understand I do not have to sign this authorization in order to get health care benefits (treatment, payment
or enrollment). However, I do have to sign an authorization form:
To take part in a research study or
To receive health care when the purpose is to create health care information for a third party.
I may revoke this authorization in writing. If I did, it would not affect any actions already taken by the
physician based upon this authorization. I may not be able to revoke this authorization if its purpose was to
obtain insurance. Two ways to revoke this authorization are:
Fill out a revocation form.
Write a letter to the physician.
Once health care information is disclosed, the person or organization that receives it may re-disclose it.
Privacy laws may no longer protect it.
Patient or legally authorized individual signature
Printed name if signed on behalf of the patient
Relationship (parent, legal guardian,