HIPAA Privacy Authorization Form

HIPAA Privacy Authorization Form
Authorization for Use or Disclosure of Protected Health Information required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
1. Authorization: I authorize Feldman Wellness Center (healthcare provider) to use and disclose the health information described below.*

Yes
2. Effective Period: This authorization for release of information covers the period of healthcare from:*

All past, present and future periods.Period of time (select dates below):
Start Date

MonthDayYear
End Date

MonthDayYear
3. Extent of Authorization*

I authorize the release of my complete health record (including records related to Chiropractic, Craniosacral Therapy, The Feldenkrais Method or Nutrition program progress notes and supplement intake.)I authorize the release of my complete health record with the exception of the following information (select below):
Exceptions:

Electronic medical records (Chiropractic, Craniosacral Therapy or The Feldenkrais Method)Nutrition program progress notes and supplement intakesOther (please specify):
4. This medical information may be used for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.*

Yes
5. This authorization shall be in force and effective as stated above in Effective Period.*

Yes
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 retroactively.*

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

Yes
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.*

Yes
Name*

First NameLast Name
Today's Date*

MonthDayYear
Signature*

Clear
** If you are using the downloadable PDF, your name is also your signature. **
Should be Empty: