HIPPA Authorization Form

HIPPA Authorization Form

Office #: 516-765-7799 | Fax #: 334-212-0223 | 3330 Park Avenue, Suite 9, Second Floor. Wantagh, NY 11793
Today's Date:*

MonthDayYear
Date
Name*

First NameLast Name
Date Of Birth: *

MonthDayYear
Date
Name Of Provider *
1.) Authorization-I authorize South Shore Psychiatry and associated staff to use and disclose the protected health information described below to:

(Individual Seeking The Information - Name of Person You Want to Have Access To Your Treatment Information)
Place Name Here
2.) Effective Period - This authorization for release of information covers the period of healthcare from:*

All, past, present, future periodsOr, Specific time periods
Extent of Authorization:*

I Authorize the release of my complete health record.Or, Specify what can be released
If you want to specify what can be released, please do so here: Specific Information
4.) This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purpose as I may direct.

5.) This authorization shall be in force until i am terminated or discharged from the practice, at which time it expires.

6.) I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent any person or entity has already acted in reliance on my authorization, or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has legal right to contest a claim.

7.) I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.

8.) I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.
Signature

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