Healthcare Privacy Document

HEALTHCARE PRIVACY DOCUMENT

Patient Information

Insurance Information

Medical History (Relevant)

Authorization to Use and Disclose Protected Health Information (PHI)

I hereby authorize the 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. I understand that the information disclosed pursuant to this authorization may include information relating to communicable disease, mental health, alcohol or substance abuse treatment, HIV/AIDS, and genetic testing unless I specifically limit disclosure below.

Recipient Name:

Recipient Address / Phone:

Description of Information to Be Disclosed

Check all that apply:

Entire medical record (all dates)
Lab results and pathology reports
Radiology and imaging reports
Progress notes and clinic notes
Billing, claims, and payment history
Mental health records (psychotherapy notes excluded unless specifically authorized)
HIV / AIDS related information
Substance abuse treatment records
Genetic testing information

Purpose of Disclosure

The PHI may be used or disclosed for the following purpose(s). Check all applicable:

Treatment/Continuity of care
Billing/Insurance/Payment
At the request of the patient or personal representative
Legal purposes
Employment/Disability determinations
Other (specify)

Expiration and Revocation

This authorization will expire on: . If no date is provided, this authorization will expire one year from the date of signature.

I understand that I may revoke this authorization at any time by giving written notice to the health care provider listed above, except to the extent that action has already been taken in reliance on this authorization. Revocation must be signed and dated to be effective.

Redisclosure and Limits on Use

I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected under federal privacy regulations. I authorize the recipient to disclose the information for the purposes described above unless I have specifically limited disclosure of categories such as HIV, mental health, or substance abuse by marking limitations in this document.

Patient Rights and Certifications

I certify that I have read and understand the contents of this form. I understand my rights under applicable privacy laws, including the right to inspect or copy the protected health information to be disclosed, the right to refuse to sign this authorization, and the right to revoke this authorization as described above.

I understand that treatment, payment, enrollment or eligibility for benefits cannot be conditioned on my signing this authorization except where allowed by law and expressly notified to me.

I authorize the release of the records as specified above and certify that the information I have provided is true and accurate to the best of my knowledge.

Acknowledgment of Privacy Practices

By signing below I acknowledge that I have been provided with, or offered the opportunity to receive, a copy of the Notice of Privacy Practices describing how my health information may be used and disclosed and the rights I have with respect to my health information.

Acknowledgment: I acknowledge receipt or offer of the Notice of Privacy Practices.

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