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______________________ A photocopy of this Authorization will be considered as an original. This Release complies with the HIPAA Privacy Rules Authorization to Disclose Health Information - 2 ____ Signature of Patient or Legal Representative ________________ Date __________________________________________ If Signed by Legal Representative, Signature of Witness Relationship to Patient:__presentatives, and assist them in any way they may request your services. 9. 10. I acknowledge receipt of a signed copy of this authorization _________ (Initials) _________________________________ed by me or my personal representative or unless the disclosure is specifically required or permitted by law. You are further authorized to discuss my case in detail with _________________ or their reizona Restriction. I understand that a recipient of medical information in California or Arizona may not further disclose medical information about me (patient) unless a new Authorization form is signauthorized re-disclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact: 7. 8. California/Arre treatment. I understand I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. I understand any disclosure of information carries with it the potential for an unending of my claim or lawsuit. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assu will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire at the end of the pe health information management department. I understand the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocationsettlement). 6. I understand I have the right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to thormation may be disclosed to and used by the following individual or organization: Authorization to Disclose Health Information - 1 5. For the purpose of: (insert reason i.e. personal injury claims/ immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse. This infrd other _________________________________________________________ 4. I understand that the information in my health record may include information relating to sexually transmitted disease, acquired_ x-ray and imaging reports from (date) ______ to (date) ______ consultation reports from (doctor's names) _________________ _______________________________ _______________________________ entire recoere appropriate) problem list medication list list of allergies immunization record most recent history and physical most recent discharge summary laboratory results from (date) ______ to (date) __________________________________________ _____________________________________________________________ 2. 3. The type and amount of information to be used or disclosed is as follows: (include dates whh information as described below: The following individual or organization is authorized to make the disclosure: _____________________________________________________________ Address __________________________ Date of Birth: ______________________ Health Record Number: _______________ S.S. No.: ___________________________ 1. I authorize the use or disclosure of the above named individual's healtbefore using this form you should consult with your attorney or physician to ensure that it addresses your specific situation. Authorization To Disclose Health Information Patient Name: _____________: (866) 627-7748 Web: www.hhs.gov States may have different laws relating to the release of information, so you should become familiar with the laws of your state before using this form. In addition, les For more information on medical information privacy you can contact: U.S. Department of Health and Human Services Office of Civil Rights 200 Independence Avenue, S.W. Washington, D.C., 20201 Phone to determine what types of information are to be released and under what circumstances. In addition, this form complies with the HIPAA (Health Insurance Portability and Accountability Act) Privacy Rully sign an authorization to disclose health information. These authorizations can be quite broad or quite limited. This form of Authorization to Disclose Health Information allows you the flexibilitylaw. However, there are circumstances when you may want to provide this information to another individual or entity (e.g. insurance companies, employers, etc.). In those circumstances, you will generase" found at findlegalforms.com. Information Authorization to Disclose Health Information Your health and medical information is considered sensitive and private and is afforded protection under the dresses your particular situation. An attorney should be consulted before negotiating any document with another party. The purchase and use of these forms is subject to the "Disclaimers and Terms of Untended to be and is not a substitute for legal advice. This form should only be a starting point for you and should not be used or signed before first consulting with an attorney to ensure that it ad Authorization. This Authorization complies with the HIPAA Privacy Rules. Keep a copy of the Authorization for future reference. Laws vary from time to time and from state to state. This form is not i(2) Information regarding the Authorization; and (3) the Authorization. Complete the form, including any requested information. The patient or the patient's legal representative must sign and date theInstructions & Checklist Authorization to Disclose Health Information This package contains: (1) Instructions and Checklist for the Authorization to Disclose Health Information (the "Authorization");