HIPAA Authorization Form

HIPAA Authorization for Use or Disclosure of Health Information

Carolina Total Child
Authorization for Disclosure of Information

I voluntarily consent to and authorize Johannah Hornak (Provider) to use or disclose my child's health information (excluding session notes) during the term of this Authorization to the recipient(s) that I have identified below.
Recipient

I authorize the release of my child's health information for the following recipient(s):
Name*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Term
I understand that Authorization will be in effect:*

Until the Provider has fulfilled this request.From the dates specified below.
From Date

MonthDayYear
Date
To Date

MonthDayYear
Date
Allowed Purpose of Disclosure of Information*
Indicate the purpose of disclosure (e.g. "at the request of the parent/guardian" is sufficient if the client is initiating this Authorization)
Type of Information to be disclosed*

All of my child's health information that the Provider has in her possession, including information relating to any medical history, mental or physical treatment received.Only the following health information:
Health information
Signature of Patient / Subject

Clear
Date Signed

MonthDayYear
Date
Parent or Legally Authorized Representative

In case the subject is beyond the legal age of consent:
Name of Parent or Guardian

First NameLast Name
Relationship to Subject
Signature of Parent / Guardian

Clear
Date Signed

MonthDayYear
Date
Should be Empty:

HIPAA Authorization for Use or Disclosure of Health Information