Authorization for Use or Disclosure of Protected Health Information (HIPAA)

This form is based on the U.S. Department of Health and Human Services HIPAAAuthorization (IHS-810).

I. Patient Information

Patient Name:

Date of Birth:

Address:

City:

State:

ZIP:

Medical Record Number (if known):

II. Authorization

I hereby authorize Northwest Psychiatry to use or disclose the following protected healthinformation as described below.

III. Information to Be Disclosed

Entire medical record

Only records related to:

Records for dates of service

Other

Only records related to:

Records for dates of service from:

Records for dates of service to:

If other, Please specify:

Sensitive information (check only if you want it included):

Mental health records (excluding psychotherapy notes unless specified)

Psychotherapy notes

Alcohol/drug abuse treatment records

HIV/AIDS or STD-related information

IV. To Whom the Information May Be Disclosed

Name/Organization:

Address:

City:

State:

ZIP:

Phone:

Fax:

V. Purpose of Disclosure

Continuing care

Personal use

Insurance/Payment

Legal/Attorney

Other (specify):

VI. Expiration and Revocation

This authorization will expire on

(date or event):

I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it.

VII. Acknowledgment

I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by HIPAA, except for information protected by 42 CFR Part 2.

I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization, except as allowed by law.

VIII. Signatures

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature:

Date

If signed by personal representative, relationship to patient:

Witness (if required):

Date

Your information will be encrypted.