HIPAA Release of Information Form

HIPAA Release of Information Form

The Health Insurance Portability and Authorization Act of 1996 ensures data privacy and security provisions for safeguarding medical information.
I authorize Legacy Behavioral Health, Inc to share and receive my medical information on my behalf to the designated recipient(s) listed below.
Patient Name

First NameMiddle NameLast Name
Patient Date of Birth

MonthDayYear
Date
Name of recipient you want your information to go to.
Address of Recipient
City, State, Zip Code
Phone and/or Fax number of Recipient
What Information shall be disclosed (please indicate the specific information if selecting 'other') - PLEASE note, MENTAL HEALTH must be checked as we are your counselor)

All Medical InformationMental Health InformationDrug and Alcohol Abuse Treatment RecordsInformation on Communicable DiseasesOther
Please indicate below what dates of service you would like us to release.
All Past, Present, and Future Periods?

All Past, Present, and Future Periods
OR Please list specific dates of service you would like released.
This release shall remain in effect for the period indicated below.
Effective Period From

MonthDayYear
Date
Effective Period Until

MonthDayYear
Date
OR
From Signing of this Agreement Until:

MonthDayYear
Date
I understand that the information I am disclosing to individuals or organizations above may not be protected by State or Federal rules governing privacy and security of data.

I hereby understand that I may revoke the authorization I have provided in sharing my health information at any time upon submitting a notice in writing to the healthcare provider and/or specified persons indicated above. I also understand that it is the policy of Legacy Behavioral Health to not release session notes to patients or their appointed representatives absent a court order.

I fully understand that in case my information has been shared prior to revocation, the knowledge acquired by the recipients cannot be revoked.

I understand that my failure to sign, or the cancellation of this authorization does not prevent me from recieving treatment that I may be otherwise entitled to receive; and shall not be required in determining whether I am eligible to receive treatment or to pay for the services that I recieve.
Signature of Patient or Representative

Clear
Name of Patient or Representative

First NameLast Name
Date Signed

MonthDayYear
Date
Name

First NameLast Name
Should be Empty: