Healthcare HIPAA Agreement

HEALTHCARE HIPAA AUTHORIZATION AND AGREEMENT

Patient Information

Patient Name:

Date of Birth:    Gender:

Insurance Information

Medical History (brief)

Authorization to Use or Disclose Protected Health Information (PHI)

I hereby authorize the use or disclosure of my protected health information as described below. This authorization is voluntary and is not a condition of treatment, payment, enrollment, or eligibility for benefits.

Medical records/clinical notes
Mental health records (psychotherapy notes excluded unless specifically authorized)
Substance abuse treatment records (if applicable)
HIV/AIDS test results and related records
Billing and payment information
Other:

I understand that the information disclosed pursuant to this authorization may include sensitive information and that the recipient may redisclose the information and it may no longer be protected by federal privacy regulations. I acknowledge that the provider will not condition treatment on signing this authorization except as permitted by law when the purpose is to obtain payment, enrollment, or eligibility for benefits.

Expiration, Revocation, and Rights

Expiration: This authorization will expire on or upon completion of the purpose specified above, whichever occurs first.

Revocation: I understand that I may revoke this authorization at any time by providing written notice to the health care provider's privacy officer. Revocation will not apply to uses or disclosures already made in reliance on this authorization prior to receipt of the revocation.

Patient Rights: I understand that I have the right to inspect and copy the protected health information to be used or disclosed, to refuse to sign this authorization, and to receive a copy of this signed authorization upon request.

Redisclosure and Conditions

Redisclosure: Information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy laws. The provider is not responsible for unauthorized redisclosure by the recipient.

Conditions: I understand that this authorization is valid only for the specific information and time period described. I authorize release of the information to the recipient named above for the stated purpose only.

Acknowledgment of Privacy Practices

I acknowledge that I have received or been offered a copy of the Notice of Privacy Practices and understand my rights regarding my protected health information.

I understand that signing this form authorizes the release of the specific information indicated and does not authorize release of any other records except as specifically stated.

Representative / Guardian (if applicable)

If signing as personal representative, provide your name and relationship and attach documentation of authority (power of attorney, guardian order, etc.).

Power of Attorney
Court Guardianship Order
Other:

Certification and Signature

By signing below, I certify that I understand this authorization, that it is voluntary, and that the information provided is accurate to the best of my knowledge. I authorize the release of the protected health information described above for the purpose stated. I acknowledge that I may receive a copy of this authorization upon request.

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