Release of Information Authorization Form

Release of Information Authorization Form

Authorize Hope and Inspiration Psychological Services to exchange, release, or obtain your protected health information in accordance with HIPAA guidelines.
- Patient Full Name
  
  First NameLast Name
- Date of Birth
  
  MonthDayYear
  Date
- Medicaid Number
- Authorization Type (select all that apply)
- Types of Information to be Released (select all that apply)
  
  Other (please specify)
- You may choose to exclude the following from this authorization:
- Recipient Name/Organization
- Recipient Address
  
  Street Address
  
  Street Address Line 2
  CityState / ProvincePostal / Zip Code
- Recipient Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Recipient Fax Number
- Purpose of Release (select all that apply)
  
  Other (please specify)
- Authorization Duration (enter date or event upon which authorization expires)
- HIPAA Privacy Notice and Right to Revoke Authorization
- I understand that I have the right to revoke this authorization at any time by providing written notice to Hope and Inspiration Psychological Services. Revocation will not affect any information already released based on prior authorization. I acknowledge that information disclosed may be subject to redisclosure and may no longer be protected by federal privacy regulations. This authorization is voluntary, and I may refuse to sign. I have received a copy of this authorization upon request.
- Signature of Patient/Parent/Representative
- Name of Parent/Representative signing
- Date Signed
  
  MonthDayYear
  Date
- Should be Empty: