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**

Iauthorize________________________________________(healthcareprovider)touseanddisclosetheprotectedhealthinformationdescribedbelowto______________________________________________(individualseekingtheinformation).

**2.EffectivePeriod**

Thisauthorizationforreleaseofinformationcoverstheperiodofhealthcarefrom:

a. □ ______________ to ______________. **OR** b. □ all past, present, and future periods.

**3.ExtentofAuthorization**

a.□Iauthorizethereleaseofmycompletehealthrecord(includingrecordsrelatingtomentalhealthcare,communicablediseases,HIVorAIDS,andtreatmentofalcoholordrugabuse).

**OR**

b.□Iauthorizethereleaseofmycompletehealthrecordwiththeexceptionofthefollowinginformation:

□Mentalhealthrecords

□Communicablediseases(includingHIVandAIDS)

□Alcohol/drugabusetreatment

□Other(pleasespecify):_______________________________________________

4.ThismedicalinformationmaybeusedbythepersonIauthorizetoreceivethisinformationformedicaltreatmentorconsultation,billingorclaimspayment,orotherpurposesasImaydirect.

5.Thisauthorizationshallbeinforceandeffectuntil___________________(dateorevent),atwhichtimethisauthorizationexpires.

6.IunderstandthatIhavetherighttorevokethisauthorization,inwriting,atanytime.Iunderstandthatarevocationisnoteffectivetotheextentthatanypersonorentityhasalreadyactedinrelianceonmyauthorizationorifmyauthorizationwasobtainedasaconditionofobtaininginsurancecoverageandtheinsurerhasalegalrighttocontestaclaim.

7.Iunderstandthatmytreatment,payment,enrollment,oreligibilityforbenefitswillnotbeconditionedonwhetherIsignthisauthorization.

8.Iunderstandthatinformationusedordisclosedpursuanttothisauthorizationmaybedisclosedbytherecipientandmaynolongerbeprotectedbyfederalorstatelaw.

Signature of patient or personal representative

Printed name of patient or personal representative and his or her relationship to patient

Date