HIPAA Privacy Authorization Form

2. Effective Period

This
 authorization
 for 
release 
of
 information
 covers
 the
 period
 of 
healthcare
 from:

OR

3. Extent of Authorization

OR

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.