Healthcare Sensitive Information Authorization

HEALTHCARE SENSITIVE INFORMATION AUTHORIZATION

I hereby authorize the use or disclosure of my protected health information as described below. I understand that this authorization is voluntary and that I may refuse to sign this authorization. I understand that treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned on signing this authorization unless the information requested is related to treatment for which the provider conditions care on receipt of information, or unless specifically permitted by law.

Patient Information

Date of Birth:    Gender:    Phone:

Insurance Information

Medical History (for context)

Authorization Details

I authorize the following entity to disclose my sensitive health information to the recipient identified below.

  Treatment / Continuity of Care      Billing / Payment      Legal / Court Proceedings      Personal Use      Other:

Information to Be Released

Select the specific protected health information to be disclosed. If unsure, state "All medical records" below.

  All medical records (comprehensive)
  Behavioral health / mental health records
  Substance abuse treatment records (consent required)
  HIV / AIDS-related records
  Genetic testing / results
  Sexual and reproductive health records
  Lab results and diagnostic reports
  Medication and prescription records
  Billing and payment records

Time period of records: From to . If left blank, authorize release of records for the most recent 12 months unless a different period is required by law.

Expiration and Revocation

This authorization will expire on: OR upon the occurrence of the following event:

I understand that I may revoke this authorization at any time by providing written notice to the disclosing provider, except to the extent that action has already been taken in reliance on this authorization. A revocation will not affect disclosures or uses already made in reliance on this authorization prior to the revocation.

Redisclosure and Legal Notice

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 standards. However, certain records such as substance abuse treatment records and HIV-related information may remain protected by additional legal safeguards; the recipient is prohibited from redisclosing such information except as permitted by law.

I acknowledge that I have read and understand the terms of this authorization and that I am entitled to a copy of this form after I sign it.

Certification and Acknowledgment

By signing below I certify that I am the patient or the patient's legal representative and that I have authority to execute this authorization. I understand that I may request a copy of this authorization and that I may revoke it as provided above.

If signed by a personal representative, complete the following: Relationship to Patient:

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