HIPAA Authorization for use or Disclosure of Health Information

This form is for use when such authorization and complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards.

Name of Patient

Date of Birth

Patient's Email

Patient's Phone Number

I authorize the following using or disclosing party:

Relation to the Patient

Phone Number

To use or disclose the following health information.

All of My Health Information

My Health Information Relating To The Following Treatment Or Condition

My Health Information Covering The Period From _________ (date) To_________(date)

Other

The Purpose Of This Authorization Is (check that all apply):

At my request

To authorize the using or disclosing party to communicate with me for marketing purposes when they receive payment from a third party to do so.

To authorize the using or disclosing party to sell my health information. I understand that the seller will receive compensation for my health information and will stop any future sales if I revoke this authorization.

Other

This Authorization Ends:

On This Date:

Or When the following event occurs:

Date

Print Name (Patient)

Your information will be encrypted.