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Permission Form for Outside Communication - Waiver of Privacy and Privilege

HIPAA Privacy Authorization Form **Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)** **

1.
Authorization**

I    
authorize
________________________________________
(health care 
provider)
 to
 use
 and
disclose 
the 
protected 
health 
information
 described
 below
 to
 ______________________________________________
(individual
 seeking
 the 
information).

**2.
Effective 
Period**

This 
authorization
 for 
release 
of
 information 
covers 
the
 period
 of 
health care
 from:

a. □ ______________ to ______________. **OR**

b. □ all past, present, and future periods.

**3.
Extent
 of
 Authorization**

a.
□
I
 authorize 
the
re lease
 of 
my
 complete 
health 
record 
(including 
records relating 
to
mental 
health care,
 communicable
 diseases,
 HIV 
or 
AIDS,
 and 
treatment
 of
 alcohol 
or
drug
 abuse).

**OR**

b.
□
I 
authorize 
the 
release 
of
 my
 complete 
health
 record
 with 
the 
exception
 of 
the
following 
information:

□
Mental
health
records

□
Communicable
diseases
(including
HIV
and
AIDS)

□
Alcohol/drug
abuse
treatment
 □
Other
(please
specify):
_______________________________________________

4.
 This
 medical 
information
 may
be 
used 
by 
the
 person 
I 
authorize 
to 
receive
 this
information 
for
 THERAPEUTIC 
treatment 
or
 consultation,
 billing
 or
 claims
 payment, 
or
 other 
purposes
 as 
I
 may 
direct.

5.
This 
authorization
 shall 
be 
in
 force
 and 
effect
 until
___________________
(date
 or
event),
 at
which 
time
 this 
authorization 
expires.

6.
I 
understand
 that
 I
 have 
the 
right
 to
 revoke
 this 
authorization, 
in
 writing,
 at 
any
time.
 I
understand
 that 
a
re vocation 
is
 not
 effective 
to 
the 
extent
 that
 any
 person 
or
 entity 
has
already 
acted 
in 
reliance
 on 
my
 authorization 
or 
if
 my
 authorization 
was
 obtained
 as 
a
condition
 of
 obtaining 
insurance 
coverage 
and 
the
 insurer 
has 
a
 legal
 right
 to 
contest 
a
claim.

7.
 I
 understand
 that 
my 
treatment,
 payment, 
enrollment, 
or
 eligibility
 for
 benefits
 will 
not 
be 
conditioned 
on
 whether 
I 
sign 
this
 authorization.

8. 
I
 understand 
that information
 used
 or
 disclosed
 pursuant 
to
 this
 authorization 
may
be
disclosed
 by 
the 
recipient
 and 
may 
no
 longer
 be 
protected 
by
 federal 
or
 state 
law.

________________________Signature of patient or personal representative

_________________________Printed name of patient or personal representative and his or her relationship to patient

_______________Date

 

Please copy and print this form and bring to your next session, signed and filled out.  You can submit the form online as well if you are able to provide a verified signature in-person during your next session.  Thank you

We are committed to your privacy. Do not include confidential or private information regarding your health condition in this form or any other form found on this website. This form is for general questions or messages to the practitioner.

Please don't put anything here:
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By clicking send you agree that the phone number you provided may be used to contact you (including autodialed or pre-recorded calls). Consent is not a condition of purchase.

We are committed to your privacy. Do not include confidential or private information regarding your health condition in this form or any other form found on this website. This form is for general questions or messages to the practitioner.

Please don't put anything here:
Please enter the words below: Click to reload image What is this?


By clicking send you agree that the phone number you provided may be used to contact you (including autodialed or pre-recorded calls). Consent is not a condition of purchase.