Patient Authorization For Release Of Protected Health Information

1. INFORMATION TO BE DISCLOSED

I authorize the release of the following information (check all that apply):

2. DISCLOSE TO / RECEIVE FROM

Name/Organization:

Address:

Phone:

Fax:

3. PURPOSE OF DISCLOSURE

4. EXPIRATION

This authorization expires on: __________ (date) OR upon the following event: _________________________ If no date or event is specified, this authorization expires twelve (12) months from the date signed.

5. YOUR RIGHTS

I understand I have the right to revoke this authorization at any time by submitting a written request, except to the extent that action has already been taken in reliance on this authorization.

I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by HIPAA. However, SUD records disclosed under this authorization may not be re-disclosed without additional authorization except as permitted by 42 CFR Part 2 as aligned with HIPAA.

I understand that treatment, payment, enrollment, or eligibility for benefits may NOT be conditioned on signing this authorization, except in limited circumstances permitted by HIPAA.

I understand I am entitled to a copy of this signed authorization.

PATIENT SIGNATURE

Date

DOB

If signed by personal representative:

Representative name:

Relationship to patient:

Authority to act (attach documentation):