Authorization for Disclosure of Protected Health Information
I, ________________, authorize the disclosure of my protected health information as described herein. I understand that this authorization is voluntary and made to confirm my direction. I understand that, if the person(s) or organization(s) that I authorize to receive my protected health information are not subject to federal and state health information privacy laws, subsequent disclosure by such person(s) or organization(s) may not be protected by those laws.
I authorize the following person(s) and/or organization(s) to disclose my protected health information (as specified below):
Name(s) ___________________________________________
Organization(s)
Address
I authorize the following person(s) and/or organization(s) to receive my protected health information, as disclosed by the person(s) and/or organization(s) above.
Name(s)
Organization(s)
Address
Specific description of the protected health information that I authorize for disclosure (authorization to disclose psychotherapy notes must be separate):
Specific description of the purpose for each use or disclosure (or write "At the request of the individual" in this space):
I understand that I may revoke this authorization in writing at any time, except to the extent that the person(s) and/or organization(s) named above have taken action in reliance on this authorization.
This authorization expires on __________________________, or in the event that
(date)
________________________________________, whichever occurs first.
(event)
I have had the opportunity to read and consider the contents of this authorization. I confirm that the contents are consistent with my direction.
_____________________________ ________________________
Signed Date
Name:
Address:
Telephone: ___ Social Security No.: ______
___________________________________________
Relationship or Authority of Personal Representative
(if applicable)