Healthcare Health AHIP Form

HEALTH AHIP AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION

Patient Information

Patient Name:    Date of Birth:

Insurance Information

Medical History (Summary)

Authorization Details

I hereby authorize the disclosure of my protected health information as described below. This authorization permits the disclosure of records by the disclosing entity and may include records created by other providers and facilities.

Medical records, clinic notes, operative reports
Laboratory and imaging results
Billing and payment records
Mental health records (psychotherapy notes require a specific authorization)
Substance use disorder treatment records (if applicable)
HIV-related information (if applicable)
Other:

Format requested: Paper Electronic (including e-mail or secure portal)

Authorization Period, Revocation, and Redisclosure

This authorization shall expire on: . If no date is provided, this authorization will expire one year from the date signed below.

I understand that I may revoke this authorization at any time by notifying the disclosing entity in writing, but that the revocation will not apply to uses or disclosures already made in reliance on this authorization. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on signing this authorization, except where allowed by law.

I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations. I release the disclosing entity and its employees from liability that may arise from the release of the information described above in accordance with this authorization.

Special Authorizations (Initial to authorize)

Initial to specifically authorize release of the following sensitive information:

Mental health records (excluding psychotherapy notes)
Psychotherapy notes (if applicable) — separate authorization required
Substance use disorder treatment records
HIV/AIDS-related information

Acknowledgment and Certification

By signing below I certify that I am the patient or the patient’s legally authorized representative. I have read and understand this authorization form, and I authorize the use or disclosure of the protected health information as described above. I understand the purposes for which the information will be used or disclosed and that I may receive a copy of this authorization upon request.

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