Fill and Sign the Authorization for Access Use and Disclosure Form

Authorization for Use and/or Disclosure of Protected Health Information Name: Department: Telephone Number: I hereby authorize the use and/or disclosure of my individually identifiable health information as described below. I understand that this authorization is voluntary. I also understand that if the person or organization authorized to receive the information is not a health plan or health care provider, the released information may be redisclosed and may no longer be protected by the federal privacy regulations.1. Person(s) or organization authorized to disclose the health information: Center for Human Resources Benefits Department 2. Person(s) or organization authorized to receive the health information: Center for Human Resources Benefits Department 3. Description of health information that may be used/disclosed: 4. Purpose for which the health information will be used/disclosed (Note: Not required if disclosure is requested by the individual): 5. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to enroll in a health plan, obtain health care treatment or payment or my eligibility for benefits. (Note: Not required if disclosure is requested by the individual.)6. I understand that I may revoke this authorization at any time by providing written notice to: I understand that my revocation will not affect any actions already taken in reliance on this authorization.7. I understand I may inspect or copy any information to be used or disclosed under this authorization. 8. Unless otherwise revoked in writing, this authorization will expire 12 months from the date signed below OR upon the occurrence of (insert name of event).____________________________________________ Date: _______Signature of Individual (or Legal Representative) (Print) Individual’s Name (Print) Name of Legal Representative (if applicable) Relationship to Individual YOU ARE ENTITLED TO A COPY OF THIS AUTHORIZATION AFTER YOU SIGN IT.