Hipaa Release And Authorization Form printable pdf download

HIPAA RELEASE AND AUTHORIZATION

I, ______________________________________________ (Principal), hereby authorize the following person to act as my

agent with regard to the matters specified in this Release:

Name: __________________________________________

Address:__________________________________________

Phone: __________________________________________

If the person designated as my agent is unable or unwilling to serve, I designate the following persons as my agent hereunder, who

shall serve in the following order:

First Alternate Agent

Name: __________________________________________

Address:__________________________________________

Phone: __________________________________________

Second Alternate Agent

Name: __________________________________________

Address:__________________________________________

Phone: __________________________________________

This Release and all of the provisions contained herein are effective immediately. I intend for my agent to be treated as I

would be treated with respect to my rights regarding the use and disclosure of my individually identifiable health information and other

medical records. This Release authority applies to any information governed by the Health Insurance Portability and Accountability Act

of 1996 ("HIPAA"), 42 USC 1320d and 45 CFR 160-164.

AUTHORIZATION

I hereby authorize any doctor, physician, medical specialist, psychiatrist, chiropractor, health-care professional, dentist, optometrist,

health plan, hospital, hospice, clinic, laboratory, pharmacy or pharmacy benefit manager, medical facility, pathologist, or other provider

of medical or mental health care, as well as any insurance company and the Medical Information Bureau Inc. or other health-care

clearinghouse that has paid for or is seeking payment from me for such services (referred to herein as a "covered entity"), to give,

disclose and release to my agent who is named herein and who is currently serving as such, without restriction, all of my individually

identifiable health information and medical records regarding any past, present or future medical or mental health condition, including

all information relating to the diagnosis and treatment of HIV/AIDS, sexually transmitted diseases, mental illness, and drug or alcohol

abuse. Additionally, this disclosure shall include the ability to ask questions and discuss this protected medical information with the

person or entity who has possession of the protected medical information even if I am fully competent to ask questions and discuss this

matter at the time. It is my intention to give a full authorization to any protected medical information to my agent.

In determining whether I am incapacitated, all individually identifiable health information and medical records shall be released to my

agent, including any written opinion relating to my incapacity that my agent may have requested. This release authority applies to any

information governed by HIPAA and applies even if my agent has not yet begun serving as my agent.

The authority given to my agent shall supersede any prior agreement that I may have made with my health-care providers to restrict

access to or disclosure of my individually identifiable health information. The individually identifiable health information and other

medical records given, disclosed, or released to my agent may be subject to redisclosure by my agent and may no longer be protected

by HIPAA.

TERMINATION

This Release shall terminate on the first to occur of: (1) two years following my death, or (2) upon my written revocation actually

received by the covered entity. Proof of receipt of my written revocation may be by certified mail, registered mail, facsimile, electronic

mail, or any other receipt evidencing actual receipt by the covered entity. This Release shall not be affected by my subsequent

disability or incapacity. There are no exceptions to my right to revoke this Release.

Hipaa Release And Authorization Form