Patient’s authorization

To Use and Disclose Health Information

This form implements the requirements for patient authorizations to use and disclose health information protected by the federal health privacy law. Except as otherwise permitted or required by that law, a health care provider may not use or disclose protected health information without an authorization that complies with the requirements of 45 C.F.R. §164.58 (c).

Re:______[Patient]

Social Security Number: ______Date of Birth:______

I am either the patient named above or the patient’s legally authorized representative. By signing this form, I authorize:

Name of Provider:______

Address:______

______

To use or disclose information to:

Name: ______

Address:______

______

Treatment dates: ______

This Authorization applies to the following health information:

complete medical, mental health, and substance abuse records

only the information specifically indicated below:

registration forms office visit notes consultations operative reports diagnostic tests x-rays, MRIs and similar tests clinical notes correspondenceprescription records medical billing statements

The purpose of the use or disclosure is legal  other [specify]: ______

I understand that my records may contain information regarding the diagnosis or treatment of HIV (the AIDS virus), other sexually transmitted diseases, drug and/or alcohol abuse, and mental illness and may refer to psychiatric and/or counseling treatment. By signing this Authorization form, I am giving permission for this information to be released as part of my requested medical records listed above.

By signing this Authorization, I am giving permission that this Authorization may be relied upon when transmitted by facsimile or e-mail. I further authorize the information to be sent by facsimile or e-mail.

By signing this Authorization, I agree to hold the recipient and the provider harmless if my faxed or mailed protected information does not reach the appropriate authorized recipient.

I understand that, with certain exceptions, I have the right to revoke this Authorization at any time. If I want to revoke this Authorization, I must do so in writing to the recipient. I understand that the revocation will not apply to information already released to this Authorization. However, the recipient may rely on this Authorization until he or she receives written notice that I am revoking it.

I understand that authorizing the disclosure of this health information is voluntary. I have the right to refuse to sign this Authorization. I need not sign this for in order to assure treatment. I understand I may inspect or copy the information to be used or disclosed, as provided in 45 C.F.R. 164-524. I understand that, once information is disclosed pursuant to this Authorization, it is possible that it will no longer be protected by the federal medical privacy law and could be re-disclosed by the person or agency that receives it.

This authorization shall expire one year from the date signed below. I have read and understand the information in this authorization form.

______

Signature of PatientPrinted Name of Patient

Date:, 20_____

—OR—

______Signature of Patient’s Representative Printed Name of Representative

Date:, 20_____

Relationship to Patient:

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