Authorization for Use or Disclosure of Protected Health Information
Required by the Health Insurance Portability and Accountability Act, 45 C.F.R.
Parts 160 and 164
2. Effective Period
This authorization for release of information covers the period of healthcare
3. Extent of Authorization
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:
at which time this authorization expires.
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.