Authorization for Release of
Protected Health Information
of
{yourName}
{date}
Authorization for Release of
Protected Health Information
of {yourName}
(Valid Authorization Under 45 CFR Chapter 164)
Statement of Intent: It is my understanding that Congress passed a law entitled the Health Insurance Portability and Accountability Act of 1996 (HIPAA) that limits use, disclosure, or release of my health information (or, sometimes herein, “protected medical information”). I am signing this Authorization because it is crucial that my health care providers readily use, release, or disclose my protected medical information to, or as directed by, that person or those persons designated in this Authorization to allow them to discuss with, and obtain advice from, others or to facilitate decisions regarding my health care when I otherwise may not be able to do so without regard to whether any health care provider has certified in writing that I am incompetent for purposes of HIPAA.
A covered entity may not condition treatment, payment, enrollment, or eligibility for benefits on whether I provide the covered entity with this Authorization.
1. Appointment of Authorized Recipients
I,{yourName} (born {dateOf}]), hereby appoint the following persons, or any of them, as Authorized Recipients for health care disclosure under the Standards for Privacy of Individually Identifiable Health Care Information (45 CFR Parts 160 and 164) under HIPAA:
{authorizedRecipient}
{authorizedRecipient21}
{authorizedRecipient22}
2. Grant of Authority
Therefore, I authorize a health care provider (a “covered entity” as defined by HIPAA) to use, release, and disclose my individually identifiable health information in accordance with and as authorized by 45 CFR Sections 164.502(a)(1)(i) and (iv), 164.502(a)(2)(i), 164.524 and 164.528.
I specifically authorize all covered persons and entities as defined in HIPAA, including, but not limited to, physicians, podiatrists, chiropractors, osteopaths, psychiatrists, psychologists, dentists, therapists, nurses, hospitals, clinics, pharmacies, laboratories, ambulance services, assisted living facilities, residential care facilities, bed and board facilities, nursing homes, medical insurance companies, and any other health care providers or affiliates to use, release, and disclose to an Authorized Recipient any of my protected medical information, including, but not limited to, reports and records concerning my medical and psychiatric history, condition, diagnosis, testing, prognosis, treatment, billing information, and identity of health care providers, whether past, present, or future, and any other information which is in any way related to my health care.
Additionally, this disclosure includes the ability to ask questions and discuss this protected medical information with the person or entity who has possession of the protected medical information even if I am fully competent to ask questions and discuss this matter at the time. It is my intention to give a full authorization for access to, disclosure, and release of ANY protected medical information by or to the persons named in this Authorization as if each person were me.
In addition to an Authorized Recipient, disclosures as described above are authorized to a Trustee or Successor Trustee of any trust, of which I am a beneficiary or a trustee, for the specific purpose of determining my capacity as defined in the trust agreement.
3. Termination
This Authorization is not affected by, and shall not terminate by reason of, my subsequent disability or incapacity. This Authorization shall terminate upon the earlier of 6 months following my death and the date my written revocation expressly referring to this Authorization is actually received by the covered entity. Proof of receipt of my written revocation may be by certified mail, registered mail, facsimile, or any other receipt evidencing actual receipt by the covered entity. Such revocation shall be effective upon the actual receipt of the notice by the covered entity except to the extent that the covered entity has taken action in reliance on it.
4. Redisclosure
By signing this Authorization, I acknowledge that the information used, disclosed, or released pursuant to this Authorization may be subject to redisclosure by an Authorized Recipient whose names are written in paragraph 1 of this Authorization and the information once disclosed will no longer be protected by the rules created in HIPAA. No covered entity may require an Authorized Recipient to indemnify the covered entity or agree to perform any act in order for the covered entity to comply with this Authorization.
5. Instructions to the Authorized Recipients
An Authorized Recipient has the right to bring a legal action in any applicable forum against any covered entity that refuses to recognize and accept this Authorization for the purposes that I have expressed. Additionally, an Authorized Recipient is authorized to sign any documents that the Authorized Recipient deems appropriate to obtain use, disclosure, or release of the protected medical information.
6. Effect of Duplicate Originals or Copies
If this Authorization has been executed in multiple counterparts, each counterpart original will have equal force and effect. An Authorized Recipient may make photocopies (including facsimiles, digital, and other reproductions) of this Authorization and each photocopy will have the same force and effect as the original.
7. My Waiver and Release
With regard to information disclosed pursuant to this Authorization, I waive any right of privacy that I may have under the authority of HIPAA or any similar state or federal act, rule, or regulation, including any amendments thereto. In addition, I hereby release any covered entity that acts in reliance on this Authorization from any liability that may accrue from the use or disclosure of my protected medical information in reliance upon this Authorization and for any actions taken by an Authorized Recipient.
8. Severability
I intend that this Authorization conform to United States and {typeA26} law. In the event that any provision of this document is invalid, the remaining provisions shall nonetheless remain in full force and effect.
I understand that I have the right to receive a copy of this Authorization. I also understand that I have the right to revoke this Authorization and that any revocation of this Authorization must be in writing.
Dated: {date}