HIPAA Privacy Authorization Form **Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)** **
I authorize ________________________________________ (healthcare provider) to use and disclose the protected health information described below to ______________________________________________ (individual seeking the information).
**2. Effective Period**
This authorization for release of information covers the period of healthcare from:
a. □ ______________ to ______________. **OR**
b. □ all past, present, and future periods.
**3. Extent of Authorization**
a. □ I authorize the release of my complete health record (including records relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse).
b. □ I authorize the release of my complete health record with the exception of the following information:
□ Mental health records
□ Communicable diseases (including HIV and AIDS)
□ Alcohol/drug abuse treatment □ Other (please specify): _______________________________________________
4. This medical information may be used by the person I authorize to receive this information for THERAPEUTIC treatment or consultation, billing or claims payment, or other purposes as I may direct.
5. This authorization shall be in force and effect until ___________________ (date or event), at which time this authorization expires.
6. 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.
7. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.
8. 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.
________________________Signature of patient or personal representative
_________________________Printed name of patient or personal representative and his or her relationship to patient