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Enter the full legal name of this person as it would appear on a legal document.
Enter the full legal name of this person as it would appear on a legal document.
A HIPAA Medical Information Release Authorization is the written consent required by the Health Insurance Portability and Accountability Act (HIPAA), 45 C.F.R. § 164.508, before a healthcare provider may disclose a patient's protected health information (PHI) to any third party other than for treatment, payment, or healthcare operations. A valid HIPAA authorization must specify: the PHI to be disclosed, the recipient, the purpose, and an expiration date or event. This is the form patients sign when authorizing release to attorneys, employers, insurance companies, family members, or other specified recipients. Fill out this free general medical information release (hipaa authorization) template online, e-sign it digitally, and download a legally valid PDF. no account or lawyer needed. Sections: Patient Information, Release Details.
(Required under HIPAA, 45 C.F.R. § 164.508) Patient Name: ______________ Date of Birth: ______________ Address: ______________ Patient ID / MRN: N/A
Name of Provider / Facility: ______________ Address: ______________
Name: ______________ Address: ______________
I authorize disclosure of the following protected health information (PHI): ______________.
NOTE: This authorization may include records related to mental health treatment, substance use disorder treatment, and HIV/AIDS status if specifically described above and expressly requested. Disclosure of certain especially sensitive information (mental health, substance abuse, HIV/AIDS) may be subject to additional state law protections.
The information is to be used or disclosed for the following purpose: ______________.
This authorization shall expire on: (One year from the date of signing). After this date, further disclosures under this authorization require a new, signed authorization.
I understand and acknowledge the following: (a) Right to Revoke: ______________. To revoke this authorization, I must provide written notice to the healthcare provider identified above. (b) Right to Refuse: I have the right to refuse to sign this authorization. Refusal to sign will not affect my ability to receive treatment, payment, or eligibility for healthcare benefits, unless this authorization is specifically required to determine insurance eligibility or to process a claim for treatment. (c) Re-disclosure: Information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by HIPAA after disclosure. (d) Copy: I have the right to receive a copy of this authorization after I sign it.
I voluntarily authorize the disclosure of the health information described above, as set forth in this form. I confirm that I am the patient (or the patient's authorized representative, if applicable), and I have provided accurate information and understand my rights in connection with this authorization.
Patient Signature: ______________________________ ______________ Date: ____________________ (If signing as patient's authorized representative:) Representative's Name: __________________________ Relationship to Patient: __________________________ Date: ____________________