HIPAA Authorization Form

IMPORTANT: This authorization allows the release of your protected health information (PHI). Please read carefully before signing.

Section 1: Authorization for Disclosure of Protected Health Information

I, (print patient name or legal representative), hereby authorize the following individual or organization:

TO DISCLOSE my protected health information to:

Section 2: Description of Information to be Released

Section 3: Purpose of Disclosure

Section 4: Expiration

This authorization will expire on:

(If left blank, this authorization will expire one (1) year from the date of signature.)

Section 5: Right to Revoke

I understand that I may revoke this authorization at any time by providing written notice to the disclosing party. I understand that a revocation will not affect any disclosures made prior to receipt of my written revocation.

Section 6: Redisclosure Notice

I understand that once my protected health information is disclosed pursuant to this authorization, it may no longer be protected by federal privacy regulations (HIPAA) and may be redisclosed by the recipient. However, I authorize such redisclosure as necessary for the purpose stated above.

Section 7: Voluntary Authorization

I have read and understand this authorization. I am signing voluntarily and am authorizing the disclosure of my protected health information as described above. I understand that I am entitled to receive a copy of this signed authorization.