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 (healthcare provider) to use and disclose the protected health information described below to (individual seeking the information).

2. Effective Period

The authorization for release of information cover the period of healthcare from:

a. to

OR

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

3. Extent of Authorization

a.
I authorize the release of my complete health record (including records relating to mental healthcare, 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 recordsCommunicable diseases (including HIV and AIDS)Alcohol/drug abuse treatmentOther (please specify):-

4. 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.

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
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.

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 any may no longer be protected by federal or state law.

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

Date