Authorization to use or disclose protected health information
I hereby authorize use or disclosure of the named individual's health information as described below:
|Patient Name||Date of Birth||Social Security Number|
|Address (Street, City, State, Zipcode)||Telephone Number|
The following individual or organization is authorized to make the
|This information may be disclosed to and used by the
following individual or organization:
|Treatment Dates||Purpose for Request|
The following information is to be disclosed
I understand that the information in my record may include information relating
to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or
infection with Human Immunodeficiency Virus (HIV). It may also include
information about behavioral or mental health services or treatment for alcohol
and drug abuse.
Redisclosure: I understand that any disclosure of information carries with it the potential for redisclosure and that the information then may not be protected by federal confidentiality rules.
Right to Revoke: I understand that I have the right to revoke the authorization at any time. I understand that my revocation must be in writing and I understand that the revocation will not apply to information already released based on this authorization.
Other Rights: (a) I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I do not need to sign this form to assure treatment; however, if this authorization is needed for participation in a research study, my enrollment in the research study may be denied. (b) I understand that I may inspect or obtain a copy of the information to be used or disclosed.
Expiration: Unless otherwise revoked, this authorization will expire on the following date, event, or condition (if I do not specify an expiration date, event or condition, this authorization will expire in six months): _____________.
|Signature of Patient of Legal Representative||Date|
|If other than the patient, indicate the name of the legal representative and the relationship to the patient|