AUTHORIZATION FOR COMMUNICATING TO OUTSIDE SOURCES For Records or Insurance

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)** **

1.
Authorization**

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).

**OR**

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

_______________Date