• 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)

     

    I authorize

  • (healthcare provider)
  • to use and disclose the protected health information described below to
  • (individual seeking the information)
  • This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.

    This authorization shall be in force and effect until

  • (date or event)
  • at which time this authorization expires.

    I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation 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.

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

    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.

  • Date Format: MM slash DD slash YYYY
14
Degree programs offered
Lisa Proulx SHOW 8