Authorization for Use or Disclosure of Protected Health Information

Authorization for Use or Disclosure of Protected Health Information
Patient Name

First Name Last Name
Date of Birth

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I hereby authorize the use or disclosure of the Protected Health Information described below to be provided to or obtained by the
following:

Name and Address of Individual/Facility/Company to Receive PHI:

	Name	Address
1
2
3
4
5
6
7

Information authorized for use or disclosure, or to be obtained:

History & Physical Discharge Summary Operative Report ER Record Consultation Lab reports Progress Notes X-ray reports
Medical information between
Date

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Date

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The information will be obtained, used, or disclosed for the following purpose only:

Insurance Continued treatment Legal At patient or patient’s representative request
I understand:
- I may revoke this authorization at any time, in writing, except revocation will not apply to information already retained, used or disclosed in response tothis authorization. I may revoke this document by presenting my written revocation as provided in the Notice of Privacy Rights. Unless revoked, theautomatic expiration date will be six (6) months from date of signature or upon occurrence of the following event:
- I release the entities listed above, their agents and employees from any liability in connection with the use or disclosure of the protected health
information. The entity authorized to disclose the information will not be compensated by the recipient for such disclosure. Normal applicable fees, such
as copy fees, may apply.

- Information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer protected by federal law.
However, the recipient may be prohibited from disclosing substance abuse information under the Federal Substance Abuse Confidentiality Requirements.

- Unless the purpose of this authorization is to determine payment of a claim for benefits, the requesting entity will not condition the provision of
treatment, payment, enrollment in a health plan, or eligibility for benefits on obtaining this authorization.

I understand that the information authorized for use or disclosure may include information which may indicate the presence of a communicable or
non-communicable disease and may include, but is not limited to, diseases such as hepatitis, syphilis, gonorrhea, and human immunodeficiency viruses
also known as Acquired immune Deficiency Syndrome (AIDS). I further understand that my medical information may indicate that I have or have been
treated for psychological or psychiatric conditions or substance abuse.
Signature of Patient *

Clear
Date

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Signature of Personal Representative *

Clear
Date

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Description of Representatives Authority to Act for the Patient
Notice of Rights: Information in your medical records that you have or may have a communicable or venereal disease is made confidential by law and
cannot be disclosed without your permission except in limited circumstances including disclosure to persons who have had risk exposures, disclosure
pursuant to an order of the court or the Department of Health, disclosure among healthcare providers or for statistical or epidemiological purposes.
When such information is disclosed, it can not contain information from which you could be identified unless disclosure of that identifying information
is authorized by you, by an order of the court of the Department of Health or by the law.
Should be Empty:

Authorization for Use or Disclosure of Protected Health Information

Medical information between

I understand:

Description of Representatives Authority to Act for the Patient