Health Insurance Portability and Accountability Act (HIPAA) Form

Health Insurance Portability and Accountability Act (HIPAA) Form

Complete this privacy authorization form prior to your appointment so that your provider can be better prepared during their time with you
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
I hereby authorize use or disclosure of protected health information about me as described below. The following specific person/class of person/facility is authorized to use or disclose information, which includes, but not limited to both verbal discussion and written communications about me to and from and between medical staff, providers and physicians at KETALINK Ketamine Center:
Your mental health provider's name
Phone Number of Your Psychiatric Provider
Please enter a valid phone number.Format: (000) 000-0000.
Email of Your Psychiatric Provider if Available
example@example.com
Duration of Authorization - This authorization for release of information covers the period of treatment from:
Please select one option
If you answered "specific dates" to the question above, please specify the dates for the release of information covering a specific time period:
(ie. 01/01/20 - 08/31/23)
Extent of Authorization - I authorize the release of my complete health record, including alcohol/substance abuse and mental health records with the exception of the following information:
Signature
I understand that:
- In the event that my information has already been shared by the time my authorization is revoked, it may be too late to cancel permission to share my health data.
- I understand that I do not need to give any further permission for the information detailed to be shared with the person(s) or organization(s) listed above.
- I understand that the failure to sign/submit this authorization or the cancellation of this authorization will not prevent me from receiving any treatment or benefits I am entitled to receive, provided this information is not required to determine if I am eligible to receive those treatments or benefits or to pay for the services I receive.
Signature
Date

MonthDayYear
Date
Should be Empty: