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Hipaa - Compliant Release Form (Authorization For Disclosure Of Protected Health Information)

HIPAA—Compliant Release Form

Authorization for Disclosure of Protected Health Information

I, ____________________________________, authorize the disclosure of my protected health information,

or the information for ___________________________________________(minor child), as described herein.

I understand that this authorization is voluntary and made to confirm my direction. I understand that, if the

person(s) or organization(s) that I authorize to receive my protected health information are not subject to

federal and state health information privacy laws,

subsequent disclosure by such person(s) or organization(s)

may not be protected by those laws.

1. I authorize the following person(s) and/or organization(s) to disclose my protected health information

(as specified below)

Name(s)

________________________________________________

Organization(s) ________________________________________________

Address

________________________________________________

2. I authorize the following person(s) and/or organization(s) to receive my protected health information,

as disclosed by the person(s) and/or organization(s) above.

Name(s)

John V. Tucker, Esquire__________________

Organization(s)

Tucker & Ludin, P.A.____________________

Address

13577 Feather Sound Drive, Ste 300 Clearwater, FL 33762

3. Specific descriptions of the protected health information that I authorize for disclosure:

All protected health information (PHI) in my medical file

All other documents in my file other than PHI

Copies of all billings for services rendered

4. Specific description of the purpose for each use or disclosure (or write “At the request of the

individual” in this space):

“At the request of this individual” for legal purposes

5. I understand that I may revoke this authorization in writing at any time, except to the extent that the

person(s) and/or authorization(s) named above have taken action in reliance on this authorization.

6. This authorization expires on ______________, or in the event that my legal case is concluded,

(date)

whichever occurs first.

***Please complete reverse side.***

Hipaa - Compliant Release Form (Authorization For Disclosure Of Protected Health Information)