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Download - HIPAA AUTHORIZATION TO RELEASE PATIENT INFORMATION … · 2020. 7. 30. · My purpose/use of the information is for o personal use; o or other (please specify) _____. 8. This authorization

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Page 1: HIPAA AUTHORIZATION TO RELEASE PATIENT INFORMATION … · 2020. 7. 30. · My purpose/use of the information is for o personal use; o or other (please specify) _____. 8. This authorization

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HIPAAAUTHORIZATIONTORELEASEPATIENTINFORMATION______________________________________________ __________________________________________Patient’sFullName Patient’sDateofBirth_______________________________________________________ __________________________________________________AddressPatient’s TelephoneNumber_______________________________________________________ __________________________________________________City,StateZipCode AnyOtherNamesUsedIherebyrequestthatPriviaMedicalGroupuse/disclosemyprotectedhealthinformation(PHI)asdirectedbelow.Specifically,IrequestthatmyPHI:

1. FromthefollowingCareCenterlocationsand/orproviders(listall):_____________________________________________________________________________________________________________

2. Besenttothefollowingperson/entityattheaddresslisted:

_____________________________________________________________________________________________________________ Name_____________________________________________________________________________________________________________Address_____________________________________________________________________________________________________________ City,StateZipCode

3.Iauthorizedisclosureofthefollowingspecificinformation(includedatesofservice):

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

NOTE:UNLESSYOUSIGNHERE,NOINFORMATIONABOUTALCOHOL/SUBSTANCEABUSE,HIV/AIDS,ORMENTALHEALTHWILLBEDISCLOSED:oYES,PLEASEDISCLOSETHISINFORMATION:______________________________________________________________________________ 4.IunderstandthatIhavetherighttoreceiveacopyofmyPHIintheformandformatandmannerIrequest,ifreadilyproducibleinthatway,orasImayotherwiseagree.Unlessotherwisespecifiedbelow,IunderstandthatmyPHIwillbeprovidedinpaperformat.IherebyrequestthatmyPHIbeprovidedinthefollowingformat:oOnanencryptedUSBdrive oOnanunencryptedUSBdrive oOther(pleasespecify)______________________________________ 5.Iunderstandthattheinformationusedordisclosedmaybesubjecttore-disclosurebythepersonorclassofpersonsorentityreceivingitandwouldthennolongerbeprotectedbyfederalprivacyregulations.6.IunderstandImayrevokethisauthorizationbynotifyingPriviaMedicalGroupinwritingofmydesiretorevokeit.However,Iunderstandthatanyactionalreadytakeninrelianceonthisauthorizationcannotbereversed,andmyrevocationwillnotaffectthoseactions.7.Mypurpose/useoftheinformationisforopersonaluse;oorother(pleasespecify)________________________________________________. 8.Thisauthorizationexpireson___________ ____,20____,ORuponoccurrenceofthefollowingeventthatrelatestomeortothepurposeoftheintendeduseordisclosureofinformationaboutme:(pleasespecify)______________________________________________________________.

FEESFORCOPIES:Whenapatientrequestsacopyofhis/herPHIforpersonaluse,federallawpermitsareasonable,cost-basedfeethatincludesonlylaborforcopyingthePHI,costsforsupplies,laborforcreatingasummary/explanationofthePHIifasummaryorexplanationwasrequested,andpostage.Ifthechargeswillexceed$25,wewillinformyouoftheapproximatechargespriortoyourrequestbeingfilled.

THISFORMMUSTBEFULLYCOMPLETEDBEFORESIGNING;INCOMPLETEFORMSWILLNOTBEPROCESSED.

_________________________________________ _____________________________ ________________________________ SignatureofPatient DateofPatient’sSignature Patient’sDateofBirth

_________________________________________ _____________________________ ________________________________ IfPatientunabletosign,signatureofPatient’sLegal DateofLegalGuardian’s/Personal DescriptionofAuthoritytoActGuardianorPersonalRepresentativeofPatient’sEstate Representative’sSignature fortheIndividual

_______________________________________________________________________________________________________________________________________

ForPriviaUseOnly

_____________ _____________ _____________ _____________ _____________ _____________ DateReceived DateProcessed Format Fee PtNotifiedofFee MedicalRecord#

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