HIPAA Release of Information

HIPAA Release of Information
HIPAA Privacy Authorization Form

*This Authorization is for the Use or Disclosure of Protected Health Information*

(Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)
Full Name*

First NameLast Name
My Silver Lake PsychologyTherapist's Name*

First NameLast Name
Authorization
I authorize my health care provider to use and disclose the protected health information described below*
(Enter Primary Care Physician or Current Therapist's Name Here)
I authorize my original health care provider to disclose information to the following individual or group*
(Enter New Therapist's Name, Group Practice, or Other Individual's Name Here)
Contact info for the person to release information to (name/phone/email)*
Effective Period
This Authorization for release of information covers the period of healthcare*

A specific start and end dateAll past, present, and future time periods
If you selected a specific start and end date, please enter that date range this authorization covers in the below box:*
(Enter dates here. Ex: 9/1/19 to 12/31/19).
Extent of Authorization
In regard to the release of my complete health record (including records relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse).*

I consent to release my complete health record as explained and stated above.I decline to release my complete health record as explained and stated above.
I authorize the release of my complete health record with the exception of the following information (check all that apply).*

Mental Health RecordsPayment Processing Information, such as credit card charges.Communicable diseases (including HIV and AIDS)Alcohol/drug abuse treatmentOtherDoes not apply-I consent to release of all records.
If "other" was selected in the above answer, please explain. If not, please enter "N/A"*
- I understand that this 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 purposes as I may direct.
- 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 that 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 a legal right to contest a claim.
- I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.
- 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.
This authorization shall be in force and effect until the date chosen below at which time this authorization expires. *

MonthDayYear
Date
Name of client or personal representative and his or her relationship to the client.*
My Signature*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

HIPAA Release of Information

Authorization

Effective Period

Extent of Authorization