HIPPA Authorization Form

HIPPA Authorization Consent Form
Main: 631-881-4569 | Fax: 631-944-8000 |

Email: dovepsychiatry624@gmail.com
Patient Name:*

First NameLast Name
Date Of Birth:*

MonthDayYear
Date
Phone Number:*
Email:*
example@example.com
Today's Date:*

MonthDayYear
Date
I hereby authorize Dove Psychiatry-NP, PLLC, to use or disclose my protected health information (PHI) as described below. I understand that this authorization is voluntary and that I may refuse to sign it.
1.) Description of Information to be Disclosed: (Please check the information you authorize to be disclosed):*

Complete Medical RecordMedical HistoryTreatment NotesLab ResultsBilling InformationOther
2.) Purpose of Disclosure: (Please check the purpose of the disclosure):*

Continuity Of CareLegal PurposesPersonal UseInsurance ClaimsOther
3.) Duration of Period for Authorization (Covers the period of healthcare from):*

All past, present and future periodsSpecific Time PeriodsOther
If You chose, "Specific Time Periods" - Please specify the timeframe.*
4.) This psychiatric behavorial health 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.
9.) Recipient of Information: (Please provide the details of the person/organization authorized to receive the information) Such as: Name/Organization, address, and phone number:
Name / Organization:      .
Address: Street Address*      City*   State*   Zip*  .
Phone Number:   Area Code   Phone Number   .
10.) Expiration of Authorization: This authorization will expire on, Date* .
11.) Right to Revoke:

I understand that I have the right to revoke this authorization at any time by providing a written notice to Mind & Soul Psychiatry PLLC. However, the revocation will not affect any actions taken before the receipt of the revocation.

12.) Re-disclosure:

I understand that information disclosed under this authorization may be subject to re-disclosure by the recipient and may no longer be protected by HIPAA.
Signature Of Patient Or Legal Guardian/Representative: *

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HIPPA Authorization Consent Form