HIPAA Authorization Client

Patient Authorization for Use and Disclosure of Protected Health Information (PHI)
Patient Name
Date of Birth

MonthDayYear
Date
Phone Number
Address
I, {patientName}, authorize LifeKey Health to:

Use and disclose my Protected Health Information (PHI) for:
Use and disclose my PHI for
Medical Treatment
Case Management
Coordination of Care
Billing and Payments
Other
Other Explanation
Disclose my PHI to
Recipient Name
Relationship
Contact Info
Expiration & Revocation: This authorization will expire on _____________ unless revoked earlier in writing I understand I may withdraw consent at any time.
Expiration Date
Signature

Clear
Date

MonthDayYear
Date
Should be Empty: