HIPAA Privacy Authorization Form

Patient Information

This information will be sent to your provider and will be kept as part of your patient records.

First Name: *

Last Name: *

Email Address *

Date of Birth: *

1. Authorization

Healthcare provider:

I authorize (above healthcare provider) to use and disclose the protected health information described below to (individual seeking the information)

2. Effective Period

a. This authorization for release of information covers the period of healthcare from:

a. This authorization for release of information covers the period of healthcare from: 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

If other, please specify

Patient Information

This information will be sent to your provider and will be kept as part of your patient records.

4. This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.

5. This authorization shall be in force and effect until (please fill date or event in the field below), at which time this authorization expires.

Check for your acknowledgement

Date or Event:

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.

Check for your acknowledgement

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

Date: *

Signature of patient or personal representative: *

Use your mouse or finger to sign in the box below.

Please review to ensure the details are correct before completion.

Triad Primary Care

Triad Primary Care