HIPPA Authorization for Release of Health-Related Information
I hereby specifically authorize Acts 4 Others, Inc. d/b/a United 4 Hope to receive information concerning my health condition for the purposes of assistance.
I hereby authorize the use or disclosure of my individually identifiable health information/protected health information described below (“Health Information”). I understand that this authorization is voluntary and that I may revoke it at any time by submitting my revocation in writing to the entity or person authorized to provide or receive the information identified below.
The specific description of Health Information that is subject of this authorization is as follows:
Entire medical record file, patient information sheets and questionnaires, patient consent forms, physician referral forms, office notes, progress notes, diagnosis, prognosis, opinions, narratives, prescriptions, radiology reports, diagnostic imaging reports, lab reports, pathology reports, operative reports, consultations, clinic records, hospital records, emergency room records, physical therapy records, skilled nurses’ notes, photographs, video tapes, records from any other doctors, insurance records, litigation files, correspondence, telephone messages, doctors’ liens, letters of protection, archived and stored documents, electronic data record-keeping, computer databases, back-up files, deleted e-mail and voice mail messages concerning treatment or services rendered to me or on my behalf or on the behalf of my un-emancipated minor children. In addition, as applicable, medical records can be released containing information about drug and/or alcohol abuse and treatments, mental health or psychiatric treatment or HIV/AIDS tested and/or treatment.
This authorization will expire on the following date or the occurrence of the following event: 180 days from the date of my signature below or at the termination of assistance, whichever may come later.
Rights concerning this authorization - By my signature below, I certify that I have read and understand the following rights:
1) I may revoke this authorization at any time prior to its expiration date by notifying the person or organization providing the Health Information or the person or organization authorized to receive the Health Information, but the revocation will not have any effect on any actions the person or organization took in reliance upon the authorization before it received my revocation.
2) I may see and receive a copy of this authorization if I ask for it.
3) I may not be required to sign this form in order to be eligible for benefits, in order to receive payments, or in order to receive benefits from the Covered Entity.
4) The Health Information that is used or disclosed under this authorization may be re-disclosed by the person or entity receiving the Health Information, and may no longer be protected by federal regulations governing privacy and confidentiality of health information
**If you are signing as a personal representative of another person, you must provide a description of your authority to act for the other person (for example, a power of attorney), and a copy of the document that authorizes you to act as the personal representative, if any.
NOTICE: YOU MAY REFUSE TO SIGN THIS AUTHORIZATION
This form may not be used to release information for treatment, payment or healthcare operations, except when the information to be released is psychotherapy notes or is certain research information.