Healthcare HIPAA Letter

HIPAA AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION

Patient Information

Date of birth:    Gender:    Medical record number:

Recipient / Provider

I authorize the following healthcare provider or facility to disclose my protected health information:

To the following recipient (person or organization authorized to receive information):

Purpose of Disclosure

Purpose (check all that apply):

Treatment   Payment/Billing   Insurance Claim   Legal   Personal Use   Other

Information to Be Disclosed

Check specific types of information to be released (check all that apply):

Entire medical record
Laboratory reports
Imaging studies (CT, MRI, X-ray)
Clinical progress notes
Billing and insurance records
Discharge summaries
Other (specify below)

Date range of records to be disclosed (if applicable): From to

Sensitive Information — Separate Authorization

I specifically authorize release of the following sensitive information if present in my record (check all that apply):

Mental health / psychotherapy notes
Substance use disorder treatment records
HIV/AIDS-related information and test results
Genetic testing information
Reproductive health / family planning

Method of Disclosure

Please indicate preferred method for release of records (check all that apply):

Patient pick-up   Mail   Fax   Electronic / secure transfer

Expiration, Revocation, and Redisclosure

This authorization will expire on:

I understand that I may revoke this authorization at any time by providing a signed written notice to the releasing provider, except to the extent that action has already been taken in reliance on this authorization. Revocation will not affect disclosures already made in reliance on this authorization.

I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations. Certain information (for example, substance use disorder treatment records) may have special protections under applicable law and redisclosure may be further restricted.

Acknowledgment and Certification

I authorize the release of the protected health information specified above. I certify that I have read and understand the terms of this authorization. I understand that signing this form is voluntary, that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on signing this form except where permitted by law, and that I may inspect or obtain a copy of the information to be used or disclosed.

Authorization Holder Certification

By signing below I certify that I am the patient or I am authorized to act on the patient's behalf and that the information provided on this form is true and correct. I further certify that I have been provided with a copy of this signed authorization upon request and that I understand the conditions listed above.

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