HIPAA PRIVACY AUTHORIZATION FORM
Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act)
Person(s) who you give permission to release information as described in this document.
Extent of Authorization
I authorize the release of my complete health record (including records relating to mental healthcare and treatment of alcohol or drug abuse, and genetic testing where applicable).
I understand that I have the right to revoke this authorization, in writing, at any time.
I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law
Signature of patient or patient representative, ef ective for a period of one year.