Form 6-21

The requirements for a valid authorization for the disclosure of protected health information are gov­erned by 45 C.F.R. § 164.508.

Authorization for Release of Protected Health Information

I, [name of patient or personal representative], intend to comply, now and in the future, with all requirements set forth in the Standards for Privacy of Individually Identifiable Health Information, known as the “Privacy Rule,” which implements the privacy requirements of the Health Insurance Portability and Accountability Act of 1996, commonly known as “HIPAA,” so that the information described below will be freely available to those described below. All provisions hereof shall be construed in accordance with that intent.

I hereby authorize each covered entity identified below to disclose [my/[name of patient]’s] individually identifiable health information as described below, which may include information concerning communicable diseases such as Human Immunodeficiency Virus (“HIV”) and Acquired Immune Deficiency Syndrome (“AIDS”), mental illness (except psy­chotherapy notes), chemical or alcohol dependency, laboratory test results, medical history, treatment, or any other such related information.

1.[My/[name of patient]’s] Additional Identification Information
Name:       
Date of Birth:       
Social Security Number:       

2.Identity of Person or Class of Persons Authorized to Make Disclosure.      All cov­ered entities as defined in HIPAA, and all other health-care providers, health plans, and health-care clearinghouses, including but not limited to each and every doctor, psychia­trist, psychologist, dentist, therapist, nurse, hospital, clinic, pharmacy, laboratory, ambulance service, assisted living facility, residential care facility, bed and board facil­ity, nursing home, medical insurance company, or any other medical provider or agent thereof having protected health information (as that term is defined in HIPAA), each being referred to herein as a “Covered Entity.”

3.Description of Information to Be Disclosed.      All health-care information, reports, and/or records concerning [my/[name of patient]’s] medical history, condition, diagno­sis, testing, prognosis, treatment, billing information, and identity of health-care pro­viders, whether past, present, or future, and any other information which is in any way related to [my/[name of patient]’s] health care. 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. It is my intention to give a full authorization to ANY protected medical information to the persons named in this authorization.

3.   Specific Information that May Be Disclosed

4.Person or Class of Persons to Whom the Covered Entity May Disclose the Above-Described Protected Health Information.      The above-described information shall be disclosed to the following individuals, each being referred to herein as “Authorized Persons.”

(a)   
      
      

(b)   
      
      

(c)   
      
      

5.Termination.      This authorization shall terminate on the first to occur of: (a) [my/[name of patient]’s] death or (b) on written revocation actually received by the Covered Entity. Proof of receipt of my written revocation may be either by certified mail, regis­tered mail, facsimile, or any other receipt evidencing actual receipt by the Covered Entity. Such revocation shall be effective on the actual receipt of the notice by the Cov­ered Entity except to the extent that the Covered Entity has taken action in reliance on this authorization.

6.Redisclosure.      By signing this authorization, I acknowledge that the information used or disclosed pursuant to this authorization may be subject to redisclosure by the autho­rized person, and the information once disclosed will no longer be protected by the rules created in HIPAA. No Covered Entity shall require my Authorized Persons to indemnify the Covered Entity or agree to perform any act in order for the Covered Entity to comply with this authorization.

7.Acknowledgment of Right to Treatment.      I understand and hereby acknowledge that the Covered Entities may not condition my receipt of health care upon my execu­tion of this authorization, and I may refuse to sign this authorization if I wish to do so.

8.Instructions to My Authorized Persons.      Authorized Persons shall have the right to bring a legal action in any applicable form against any Covered Entity that refuses to rec­ognize and accept this authorization for the purposes that I have expressed. Additionally, Authorized Persons are authorized to sign any documents that they deem appropriate to obtain the protected medical information.

9.Revocation.      This authorization may be revoked in writing by me at any time.

10.Valid Document.      A copy or facsimile of this original authorization shall be accepted as though it was an original document.

11.My Waiver and Release.      I hereby release any Covered Entity that acts in reliance on this authorization from any liability that may accrue from releasing [my/[name of patient]’s] protected medical information to Authorized Persons and for any actions taken by the Authorized Persons. I also specifically prohibit Authorized Persons from filing a complaint of any kind against any Covered Entity that complies with the direc­tions of my Authorized Persons hereunder to the extent that such a complaint purports to charge said Covered Entity with any violation of the Privacy Rules or other federal or state laws related to disclosure of medical records as a result of their compliance with said directions.

Date: ___________________________________

___________________________________
Signature of patient or personal representative

Printed name of personal representative:       

Description of personal representative’s authority: