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  • 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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0517 HIPAA AUTHORIZATION TO RELEASE PATIENT INFORMATION ______________________________________________ __________________________________________ Patient’s Full Name Patient’s Date of Birth _______________________________________________________ __________________________________________________ Address Patient’s Telephone Number _______________________________________________________ __________________________________________________ City, State Zip Code Any Other Names Used I hereby request that Privia Medical Group use / disclose my protected health information (PHI) as directed below. Specifically, I request that my PHI: 1. From the following Care Center locations and/or providers (list all): _____________________________________________________________________________________________________________ 2. Be sent to the following person / entity at the address listed: _____________________________________________________________________________________________________________ Name _____________________________________________________________________________________________________________ Address _____________________________________________________________________________________________________________ City, State Zip Code 3. I authorize disclosure of the following specific information (include dates of service): _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ NOTE: UNLESS YOU SIGN HERE, NO INFORMATION ABOUT ALCOHOL/SUBSTANCE ABUSE, HIV/AIDS, OR MENTAL HEALTH WILL BE DISCLOSED: o YES, PLEASE DISCLOSE THIS INFORMATION: ______________________________________________________________________________ 4. I understand that I have the right to receive a copy of my PHI in the form and format and manner I request, if readily producible in that way, or as I may otherwise agree. Unless otherwise specified below, I understand that my PHI will be provided in paper format. I hereby request that my PHI be provided in the following format: o On an encrypted USB drive o On an unencrypted USB drive o Other (please specify) ______________________________________ 5. I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or entity receiving it and would then no longer be protected by federal privacy regulations. 6. I understand I may revoke this authorization by notifying Privia Medical Group in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions. 7. My purpose/use of the information is for o personal use; o or other (please specify) ________________________________________________. 8. This authorization expires on ___________ ____, 20____, OR upon occurrence of the following event that relates to me or to the purpose of the intended use or disclosure of information about me: (please specify) ______________________________________________________________. FEES FOR COPIES: When a patient requests a copy of his/her PHI for personal use, federal law permits a reasonable, cost-based fee that includes only labor for copying the PHI, costs for supplies, labor for creating a summary/explanation of the PHI if a summary or explanation was requested, and postage. If the charges will exceed $25, we will inform you of the approximate charges prior to your request being filled. THIS FORM MUST BE FULLY COMPLETED BEFORE SIGNING; INCOMPLETE FORMS WILL NOT BE PROCESSED. _________________________________________ _____________________________ ________________________________ Signature of Patient Date of Patient’s Signature Patient’s Date of Birth _________________________________________ _____________________________ ________________________________ If Patient unable to sign, signature of Patient’s Legal Date of Legal Guardian’s/Personal Description of Authority to Act Guardian or Personal Representative of Patient’s Estate Representative’s Signature for the Individual _______________________________________________________________________________________________________________________________________ For Privia Use Only _____________ _____________ _____________ _____________ _____________ _____________ Date Received Date Processed Format Fee Pt Notified of Fee Medical Record #

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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

0517

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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