HIPAA AUTHORIZATION FORM
I, , hereby authorize the use or disclosure of my protected health information as described below:
. AUTHORIZED PERSONS TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION
is authorized to disclose the following protected health information to of , .
. DESCRIPTION OF INFORMATION TO BE DISCLOSED
The health information that may be disclosed is:
. PURPOSE OF THE USE OR DISCLOSURE
The purpose of this use or disclosure is .
. VALIDITY OF AUTHORIZATION FORM
This Authorization Form is valid beginning on and expires
I understand that the information used or disclosed under this Authorization Form may be subject to re-disclosure by the person(s) or facility receiving it and would then no longer be protected by federal privacy regulations.
I have the right to refuse to sign this Authorization Form. If signed, I have the right to revoke this authorization, in writing, at any time. I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.