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 AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION

(HIPAA-Compliant PHI Release Form)

 

 

I, ___________________________________, authorize the disclosure of my protected health information1 as described herein.  I understand that this authorization is voluntary and made to confirm my direction.  I understand that, if the person(s) or organizations(s) that I authorize to receive my protected health information are not subject to federal and state health information privacy laws,2 subsequent disclosure by such person(s) or organizations(s) may not be protected by those laws.

 

1.  I authorize the following  person(s) and/or organization(s) to disclose my  protected health informa-

     tion (as specified below):

 

       Names(s)_______________________________________________________________________

 

       Organization(s)__________________________________________________________________

 

       Address________________________________________________________________________

 

       Telephone ________________ FAX ________________ Email ___________________________

 

2.  I authorize ROGER N. MEYER, doing business as "...of a different mind" to receive my  protected

     health information, as disclosed by the  person(s) and/or organizations(s) above.  Roger N. Meyer's

     address and contact information is found at the bottom of this page.

 

3.  I understand that  specific authorization is  required for  disclosure of  mental   health records and

     other protected health records is required.  That authorization is found on the back side of this

     form.

 

A specific description of my  protected  health  information that I authorize for disclosure is as follows:

 

 

 

4.  At my request, described below is the purpose for each use or disclosure:

 

 

 

5.  I understand that I may revoke this authorization in writing at any time, except to the  extent that the

     person(s)  and/or organization(s) named  above have  taken action in  reliance  on this authorization.

 

6.  This authorization expires on _______________________,or  upon  the date that  Roger N. Meyer's                                                                       (Date)

     contract  relationship to me as my authorized representative or advocate has been terminated, which

     ever occurs first.  In no case is this release and authorization to remain in effect for more than one

     calendar year beyond the date of my signature on the reverse side of this form.

 

______________________________,Social Security Claimant Representative/Advocate___________

                                                                                                                                                                    (Date)

 

For authentication, the reverse side of this authorization must be completed

 

OADM Client HIPAA PHI Authorization February 2005

 

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