HIPAA Privacy Authorization Form

Please correct the errors described below.

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

1. Authorization

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:

Or

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.

Your information will be encrypted.

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