Patient Consent & Authorization for Release of Protected Health Information

Patient Name

Date of Birth

Address

City

State

ZIP Code

Telephone Number

E-mail Address

Patient Authorization

I hereby authorize the release, use or disclosure of my health information as follows

Patient Full Name

This authorization pertains to the following type of medical information about me:

I hereby authorize,

Name of individual(s) and/or organization providing information

to release the above-described information to

Name of individual(s) and/or organization receiving this information

I understand that, per my request, this authorization will permit the above-named parties to use or disclose the identified health information for purposes beyond treatment, payment, or healthcare operations as provided by the Health Insurance Portability and Accountability Act of 1996 (HIPPA).

I understand that I may revoke this authorization at any time by providing written notification to:

The revocation will be effective on the date it has been received and processed by the above-named recipient. I understand that the revocation does not apply to actions taken in reliance upon this authorization prior to the effective date of revocation. I also understand that i do not have to sign this authorizations in order to receive treatment, payment, or to enroll or be eligible for benefits.

Unless I request in writing otherwise, I understand that this authorization will expire on

Expiration date or event

If I do not specify an expiration date or event, this authorization will expire ninety (90) days from the date on which I signed this authorization.

I understand that the information used or disclosed pursuant to this authorization may be subject to redisclosure by the named recipient, and may no longer be protected by HIPAA's privacy rules after the authorized disclosure.

Patient or Personal Representative

Full Name:

Date:

Relationship to Patient:

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