Healthcare Viewing Authorization

HEALTHCARE VIEWING AUTHORIZATION

Facility Name:    Patient Name:

Date of Birth:    Medical Record No.:

Authorized Viewer(s)

Authorized Viewer 1 — Name:   Relationship:

Authorized Viewer 2 — Name:   Relationship:

Scope of Viewing

The undersigned authorizes the Facility to permit the authorized viewer(s) to view the following protected health information (check all that apply):

Medical records and clinical notes
Diagnostic images (X-ray, MRI, CT)
Laboratory test results
Billing and insurance records
Mental health records (requires patient authorization)
Substance use treatment records (requires patient authorization)
HIV/AIDS related information
Other:

Purpose of Viewing

Time Period and Expiration

This authorization is effective immediately upon signature and will expire on:    If no date entered, expiration will occur one year from date of signature unless otherwise revoked in writing.

Revocation and Right to Revoke

I understand that I may revoke this authorization at any time by providing a written notice of revocation to the Facility's Health Information Management department. Revocation will not apply to information already released in reliance on this authorization prior to receipt of the revocation.

Redisclosure and Limitations

I acknowledge that information disclosed pursuant to this authorization may be subject to re-disclosure by the authorized viewer and may no longer be protected by federal privacy regulations. The Facility is not responsible for unauthorized re-disclosure by the recipient.

Fees

I understand that fees for copying or retrieval may apply in accordance with Facility policy and applicable law. I agree to be responsible for any reasonable administrative fees for access or copying, unless otherwise required by law.

Acknowledgment and Certification

By signing below, I certify that I am the patient or have the legal authority to act on the patient's behalf. I have read and understand the terms of this authorization. I authorize the Facility to permit the authorized viewer(s) to view the specified information for the stated purpose. I understand that signing this form is voluntary and will not affect the patient's right to receive treatment, payment, enrollment, or eligibility for benefits.

If signing as legal representative, attest to authority basis (e.g., guardian, power of attorney):

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