Authorization to Disclose Health Information

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This Authorization to Disclose Health Information allows you to determine what type of medical information can be released and under what circumstances. This form is for use in all states and is available for instant download.

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Your health and medical information is considered private and is afforded protection under federal and state laws. This Authorization to Disclose Health Information allows you the flexibility to determine what types of information can be released and under what circumstances. This form also complies with HIPAA (Health Insurance Portability and Accountability Act) Privacy Rules. This Authorization to Disclose Health Information can be revoked at any time.

These important provisions are included in this Authorization to Disclose Health Information:
  • Patient Information: Contains the patientís name, date of birth, social security number and health record number;
  • Authorization: Sets out the specific individual or organization authorized to make the disclosure;
  • Type of Information to be Disclosed: Sets out the type and the date for the information being released;
  • Purpose: Sets out the specific purpose for which the information is being disclosed;
  • Signature: This provision sets forth a signature line for the patient or the patientís legal representative.

Protect yourself and your rights by using our professionally prepared up-to-date forms.

This attorney prepared packet includes:
  1. Instructions and Checklist
  2. General Information
  3. Authorization to Disclose Health Information for use in all states
State Law Compliance: This form complies with the laws of all states
Number of Pages5
DimensionsDesigned for Letter Size (8.5" x 11")
EditableYes (.doc, .wpd and .rtf)
UsageUnlimited number of prints
Product number#21928
This is the content of the form and is provided for your convenience. It is not necessarily what the actual form looks like and does not include the information, instructions and other materials that come with the form you would purchase. An actual sample can also be viewed by clicking on the "Sample Form" near the top left of this page.












Authorization to Disclose Health Information










This Packet Includes:
1. Instructions and Checklist;
2. General Information
3. Authorization to Disclose Health Information





Instructions and Checklist
Authorization to Disclose Health Information

   Complete the form, including any requested information.  

   The patient or the patients legal representative must sign and date the 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 intended 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 addresses 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 Use” found at www.findlegalforms.com.






General Information
Authorization to Disclose Health Information

Your health and medical information is considered sensitive and private and is afforded protection under the law.  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 generally 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 flexibility 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 Rules

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: (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, before using this form you should consult with your attorney or physician to ensure that it addresses your specific situation.





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Authorization To Disclose Health Information


Patient Name: ______________________
Health Record Number: _______________

Date of Birth: ______________________

S.S. No.: ___________________________


1.   I authorize the use or disclosure of the above named individuals health information as described below:

2.   The following individual or organization is authorized to make the disclosure:

_____________________________________________________________

Address ______________________________________________________

_____________________________________________________________

3.   The type and amount of information to be used or disclosed is as follows:
(include dates where 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) ______
[ ]    x-ray and imaging reports   from (date) ______   to (date) ______
[ ]    consultation reports from       (doctors names) _________________

_______________________________

_______________________________
[ ]    entire record
[ ]    other  _________________________________________________________
   ______________________________________________________________
   ______________________________________________________________

4.   I understand that the information in my health record may include information relating to sexually transmitted disease, acquired 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.

5.   This information may be disclosed to and used by the following individual or organization:

For the purpose of: (insert reason i.e. personal injury claims/settlement).

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 the 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 revocation 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 pending of my claim or lawsuit.

7.   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 assure 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 unauthorized 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: _________________________________________
   ____________________________________________________________________

8.   California/Arizona 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 signed by me or my personal representative or unless the disclosure is specifically required or permitted by law.

9.   You are further authorized to discuss my case in detail with _________________
   __________________________________________________________________
or their representatives, and assist them in any way they may request your services.

10.   I acknowledge receipt of a signed copy of this authorization _________  (Initials)


_____________________________________      ________________
Signature of Patient or Legal Representative         Date


__________________________________________
If Signed by Legal Representative, Signature of Witness

Relationship to Patient:________________________



A photocopy of this Authorization will be considered as an original.
This Release complies with the HIPAA Privacy Rules

Customer Reviews

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Reviews: 1


Johnson City,

TN

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The whole process was under 5 minutes. Saved time, gas, didn't have to go to Drs. office (1 hr away) to sign a form. It was a quick needed form for my disability claim, it was easily accepted by the insurance. Yes, I will use them again and spread the word. You are awesome!


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