Massachusetts Department Of Public Health Authorization For Release Of Information Permission To Share Information (Page 2 of 2) in pdf

Massachusetts Department Of Public Health Authorization For Release Of Information Permission To Share Information Page 2

Massachusetts Department of Public Health

Authorization for Release of Information

SECTION V – Who May Receive My Information

The person or organization listed in Section IV may share the information I listed in Section II with this person(s) or

organization:

Name

Organization

Address

I understand that the person(s) or organization listed in this section may not be covered by federal or state privacy

laws, and that they may be able to further share the information that is given to them.

SECTION VI – How Long This Permission Lasts

This permission to share my information is good until

Indicate date or event

If I do not list a date or event, this permission will last for one year from the date it is signed.

•

I understand that I can change my mind and cancel this permission at any time. To do this, I need to write a

letter to ____________________, and send it or bring it to the place where I am now giving

(Fill in name of person or organization)

this permission (or fill in specific location) If the information has already been given out by, I understand that it is

too late for me to change my mind and cancel the permission.

•

I understand that I do not have to give permission to share my information with the person(s) or organization I

listed in Section V.

•

I understand that if I choose not to give this permission or if I cancel my permission, I will still be able to receive

any treatment or benefits that I am entitled to, as long as this information is not needed to determine if I am

eligible for services or to pay for the services that I receive.

SECTION V – Signature

Please sign and date this form, and print your name.

Your Signature

Date

Print Your Name

If this form is being filled out by someone who has the legal authority to act for you (such as the parent of a

minor child, a court appointed guardian or executor, a custodial parent, or a health care agent), please:

Print the name of the person filling out this form:

Signature of the person filling out this form:

Describe how this person has legal authority for this individual:

HIPAA-compliant Authorization 9/08 Form 5-A

Massachusetts Department Of Public Health Authorization For Release Of Information Permission To Share Information Page 2