Authorization Form - Hipaa Release Of Information printable pdf download

HIPAA Release of Information

AUTHORIZATION FORM

I, ______________________________________hereby authorize _______________________________

and its affiliates, its employees and agents (collectively ____________________________), to release to

________________________________________________ [Insert full name of person/organization]

my personal health information maintained by ____________________________________________

(e.g., information relating to the diagnosis, treatment, claims payment, and health care services provided

or to be provided to me and which identifies my name, address, social security number, Member ID

number) except the following information about me:

___________________________________________________ [DESCRIBE INFORMATION NOT

TO BE DISCLOSED, IF ANY] for the purpose of helping me to resolve claims and health benefit

coverage issues. I understand that any personal health information or other information released to the

person or organization identified above may be subject to re-disclosure by such person/organization and

may no longer be protected by applicable federal and state privacy laws.

This authorization is valid from the date of my/my representative’s signature below and shall expire

the earlier of __________________________ [INSERT DATE/EVENT UPON WHICH THIS

AUTHORIZATION EXPIRES] or the date my coverage ends with _____________________________.

I understand that I have a right to revoke this authorization by providing written notice to ____________

___________________________________________. However, this authorization may not be revoked if

_____________________________________________________________, it’s employees or agents

have taken action on this authorization prior to receiving my written notice. I also understand that I have

a right to have a copy of this authorization.

I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My

refusal to sign will not affect my eligibility for benefits or enrollment or payment for or coverage of services.

Name of Member: _______________________________________________________

Signature of Member: ____________________________________________________

Date: ______________________________

If applicable, Legal Representatives sign below:

By signing this form, I represent that I am the legal representative of the Member identified above

and will provide written proof (e.g., Power of Attorney, living will, guardianship papers, etc.) that I am

legally authorized to act on the Member’s behalf with respect to this authorization form.

Name of Legal Representative: _________________________________________________________

Signature of Legal Representative: _____________________________________________________

Date: __________________________________________

Name of Witness: ________________________________________________________

Signature of Witness: _____________________________________________________

Authorization Form - Hipaa Release Of Information