• HIPAA Privacy Authorization Form

  • Authorization for use or disclosure of protected health information

    (Required by the Health insurance Portability and Accountability Act, 45, C.F.R. parts 160 and 164

  •  -  - Pick a Date
  •  -
  • 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.

  • Please send this form and you can sign it at the time of your visit.  A copy will be made a placed in your record.

  •  
  • Should be Empty: