HIPAA Release Form

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)touse anddisclosetheprotectedhealthinformationdescribedbelowto ______________________________________________(individualseekingtheinformation).

**2.EffectivePeriod** Thisauthorizationforreleaseofinformationcoverstheperiodofhealthcare from:

a. ______________ to ______________.

**OR**

b. all past, present, and future periods.

**3.ExtentofAuthorization** a.Iauthorizethereleaseofmycompletehealthrecord(includingrecords relatingtomentalhealthcare,communicablediseases,HIVorAIDS,andtreatmentof alcoholordrugabuse).

**OR**

b.Iauthorizethereleaseofmycompletehealthrecordwiththeexception ofthefollowinginformation:

Mentalhealthrecords Communicablediseases(includingHIVandAIDS) Alcohol/drugabusetreatment Other(pleasespecify):_______________________________________________

4.ThismedicalinformationmaybeusedbythepersonIauthorizetoreceive thisinformationformedicaltreatmentorconsultation,billingorclaimspayment,or otherpurposesasImaydirect.

5.Thisauthorizationshallbeinforceandeffectuntil___________________(date orevent),atwhichtimethisauthorizationexpires.

6.IunderstandthatIhavetherighttorevokethisauthorization,inwriting, atanytime.Iunderstandthatarevocationisnoteffectivetotheextentthatany personorentityhasalreadyactedinrelianceonmyauthorizationorifmy authorizationwasobtainedasaconditionofobtaininginsurancecoverageandthe insurerhasalegalrighttocontestaclaim.

7.Iunderstandthatmytreatment,payment,enrollment,oreligibilityfor benefitswillnotbeconditionedonwhetherIsignthisauthorization.

8.Iunderstandthatinformationusedordisclosedpursuanttothis authorizationmaybedisclosedbytherecipientandmaynolongerbeprotectedby federalorstatelaw.

Signature of patient or personal representative

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

Date

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