HIPAA Authorization Form Authorization for Use and Disclosure of Protected Health Information
1. Patient Information I hereby authorize the healthcare provider or organization identified below to use and/or disclose my protected health information (PHI) as described in this authorization form.
2. Information to Be Disclosed The following health information may be used or disclosed: medical records, laboratory results, diagnostic imaging reports, treatment summaries, and/or other records as specified below. This authorization covers records from the date range indicated.
3. Purpose of Disclosure The purpose of this disclosure is as specified below. I understand that the information may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations.
4. Right to Revoke I understand that I may revoke this authorization at any time by submitting a written request, except to the extent that action has already been taken in reliance on this authorization. This authorization expires on the date specified below or one year from the date of signature, whichever comes first.
Patient Name:
Date of Birth:
Medical Record #:
Authorized Recipient:
Purpose:
Patient Signature Date
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