HIPAA Authorization Form Sample-Customize for Your Practice

Federal Register/Vol 64, N. 212/Wednesday, November 3, 1999/Proposed Rules 60065

Appendix to Subpart E of Part 164-Model Authorization Form

AUTHORIZATION FOR RELEASE OF INFORMATION

Section A: Must be completed for all authorizations

I hereby authorize the use of disclosure of my individually identifiable health information as described below. I understand that this authorization is voluntary. I understand that if the organization authorized to receive the information is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations.

Patient name: _______________________________________ ID Number: ______________________________

Persons/organizations providing the information: Person/organizations receiving the information:

__________________________________________ ___________________________________________

__________________________________________ ___________________________________________

__________________________________________ ___________________________________________

__________________________________________ ___________________________________________

Specific description of information (including date(s)): ______________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Section B: Must be completed only if a health plan or a health care provider has requested the authorization

1. The health plan or health care provider must complete the following:

a. What is the purpose of the use or disclosure? _______________________________________________

______________________________________________________________________________________

b. Will the health plan or health care provider requesting the authorization receive financial or in-kind compensation in exchange for using or disclosing the health information described above?

Yes ____ No _____

2. The patient or the patient's representative must read and initial the following statements:

a. I understand that my health care and the payment for my health care will not be affected if I do not sign this form. Initials: ________

b. I understand that I may see and copy the information described on this form if I ask for it, and that I get a copy of this form after I sign it. Initials: __________

Section C: Must be completed for all authorizations

The patient or the patient's representative must read and initial the following statements:

1. I understand that this authorization will expire on __ __/__ __/__ __ __ __ (DD/MM/YYYY) Initials: _________

2. I understand that I may revoke this authorization at any time by notifying the practice in writing, but if I do it won't have any affect on any actions they took before they received the revocation. Initials: ________

______________________________________________________ __________________________

Signature of patient or patient's representative Date

(Form MUST be completed before signing)

Printed name of patient's representative: ___________________________________________________

Relationship to the patient: _______________________________________________________________

*YOU MAY REFUSE TO SIGN THIS AUTHORIZATION*

You may not use this form to release information for treatment or payment except
when the information to be released is psychotherapy notes or certain research information.

[FR Doc. 99-28440 Filed 10-28-99; 4:45pm