"Hipaa Privacy Authorization Form"

ADVERTISEMENT
ADVERTISEMENT

Download "Hipaa Privacy Authorization Form"

291 times
Rate (4.3 / 5) 15 votes
Go to Complete HIPAA Instructions
Reset or Clear Form
Print Form
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)
a.
from (date) _________________ - to (date)_______________________ OR
b
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,
a.
communicable diseases, HIV or AIDS, and treatment of alcohol/drug abuse). OR
b.
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):
tt
Name ____________________________________________ Relationship _____________________
Name ____________________________________________ Relationship _____________________
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
Go to Complete HIPAA Instructions
Reset or Clear Form
Print Form
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)
a.
from (date) _________________ - to (date)_______________________ OR
b
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,
a.
communicable diseases, HIV or AIDS, and treatment of alcohol/drug abuse). OR
b.
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):
tt
Name ____________________________________________ Relationship _____________________
Name ____________________________________________ Relationship _____________________
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