HIPAA Privacy Authorization Form/Release of Information

HIPAA Privacy Authorization Form/Release of Information

**Authorization for use or disclosure of protected health information (PHI). This is required by the HIPPA, 45 C.F.R. Party 160 and 164.
Prescribers:
Dr. Thomas Park, M.D.
Yan Yan Wang, DNP, PMHNP
Clinical Therapists:
Carolin Mann-Bomar, MS, LLP
Robyn E. Glickman, PhD, LLP
Janice D. Wright, LMSW
Gasper G. Novara, LMSW
Ania Austin, LLP
Rula Mohammad, LLP
Angela Bologna, TLLP
Patricia Willis, LLP
Raymond Small, PhD
Patient Full Name:*
Date of Birth:*

MonthDayYear
Date
I authorize Thomas Park, M.D. & Associates to use, request, use, disclose or receive PHI to/from the following individual/organization:*
Enter Individual or Organization's Name
Phone Number:*
Format: (000) 000-0000.
Fax Number:*
Format: (000) 000-0000.
This authorization is valid from today's date through (date) :*

MonthDayYear
Date
(If not date is listed, the authorization will expire one year from today's date).
Information to be released:
All RecordsMedication ListDiagnosesEvaluationsLab/Test ResultsProgress NotesPsychotherapy NotesPsych Test ResultsFinancial/Billing InfoOther
By signing below, I hereby authorize the release of any and all specific health related documents as indicated above to the designated recipient listed. I understand that, at any time, this authorization may be revoked when the office receives written notification. That revocation will not be effective as the disclosure of records whose release I have previously authorized, or where other action has been taken in reliance on an authorization I have signed.
Client Signature (or guardian if applicable):*

Clear
Date:*

MonthDayYear
Date
Should be Empty:

HIPAA Privacy Authorization Form/Release of Information

Information to be released: