HIPAA AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION

Patient Name:

DOB:

Address:

Phone Number:

Recipient of Information Name:

Address:

Phone Number:

Relationship to Patient:

Information to be Disclosed:

(Describe the specific health information to be disclosed, e.g., medical records, test results, billing information, etc.)

Purpose of Disclosure:

(Indicate the purpose for the disclosure, e.g., for treatment, payment, healthcare operations, etc.)

Expiration of Authorization:
This authorization is valid until the signee revokes it with written documentatio.
(If no expiration date is provided, the authorization is valid in perpetuity from the date signed.)

Patient Rights:

- I understand that I have the right to revoke this authorization at any time by providing written notice to the health care provider, except where actions have already been taken based on this authorization.
- I understand that the information disclosed may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations.
- I understand that signing this authorization is voluntary and that I am not required to sign it in order to receive treatment, payment, or healthcare services.

Signature of Patient or Legal Representative:
I have read and understand the information provided in this authorization. I consent to the disclosure of my health information as described above.

If signed by legal representative, relationship to patient:

Date: