Hipaa Privacy - Release Of Information Authorization Form printable pdf download

Lowcountry Psychiatric Associates

25 Clark Summit Dr F-201

Bluffton SC 29910

HIPAA Privacy - Release of Information Authorization Form

Patient Name ___________________________________ DOB: ______________________

Address ___________________________City______________State______Zip__________

**1. Authorization**

I authorize the following provider(s):

□ Joseph Walters □ Richard Ford □ Suzanne Veilleux □ Marianne Osentoski

□ Vicki Bonnell and/or □ All Providers to request and/or release the

disclosure of the protected health information described below to and/or from the

following individuals/organizations:

Name of Person/Practice/Organization:____________________________________

Address: ___________________________City_____________State_____Zip__________

Phone #:________________________________Fax #:______________________________

Name of Person/Practice/Organization:____________________________________

Address: ___________________________City_____________State_____Zip__________

Phone #:______________________________Fax #:________________________________

**2. Effective Period**

This authorization for release of information covers the period of

healthcare from this date forward unless I revoke the authorization in writing.

**3. Extent of Authorization**

□ I authorize the release of my complete health record (including recordsrelating to mental

healthcare, communicable disease, and treatment of alcohol or drug abuse).

**OR**

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): _______________________________________________

I understand that my records are protected by the Federal Confidentiality Regulations as well as the

provisions of HIPPA and cannot be disclosed without my written consent unless otherwise provided for in

the regulations. I also understand that I have the right to revoke this authorization, in writing, at any

time. 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.

Patient/Guardian Signature _____________________________DATE_____________

Printed name of Patient/Guardian__________________________________________

Hipaa Privacy - Release Of Information Authorization Form