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

Today's Date

Month Day Year

Full Name *

First Name Last Name

E-mail *

Phone Number *

Area Code Phone Number

I authorize Dr. Corey Howard to use and disclose the protected health information described below to: *

This authorization for release of information covers the period of healthcare from/to? *

Please check all that apply *

I authorize all past, present and future periods I authorize the release of my complete health records I authorize the release of complete records with the exception of the following (mark those that apply) Mental health records Alcohol/drug abuse treatment

Other specific records I would like to exclude:

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. *

Yes No

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.

Signiture *

Please Type name in ALL CAPS

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.

HIPAA Privacy Authorization Form