HIPAA Authorization Form

HIPAA Authorization Form

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We use this form to authorize requests for information AND/OR disclosure of information.
Client's Name*
Date of Birth*

MonthDayYear
Date
The client is:*

Under 18-years-old18-years-old or older and legally independent from parents18-years-old or older with agent serving as power of attorney or guardian
Please upload your power of attorney or guardianship paperwork here (if you don't have a digital copy on hand at this time, please stop by the front desk or email a copy later to HIPAA@childrensteam.com):

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Authorization to Release or Obtain Information

I, the client's legal parent/guardian/power of attorney or legally independent client 18-years-old or older, hereby authorize Children’s TEAM to release or obtain for the client named above individually identifiable information, including contact information, information about physical or mental health, information about health care services, information about education services and information about payment for services under the circumstances described below.
Purpose (check one or more)*

for healthcare servicesfor communication between the client's therapist(s) and teacher(s)/relevant school personnelfor legal counselfor clients 18-years-old or older, permit communication between Children's TEAM and parentsOther
For clients 18-years-old or older, names (first and last) of individuals information can be disclosed to or requested from:
*Type of information to be disclosed or requested in oral or written form:*

ALL information forms possibly needed for the client's evaluation or treatment (Medical Records, Evaluations, IQ Testing, Psychological Assessment, Swallow Study, Student Records, IEP or Learning Plan, Billing Information)Other
I understand that:
● This authorization must be filled out completely. A copy is as valid as the original.
● Children’s TEAM will not refuse to provide health care services to me based on my refusal to authorize the use or disclosure of the client’s personal health information for purposes unrelated to those health care services.
● I may revoke this authorization at any time by notifying Children’s TEAM in writing, but if I do, it won’t affect any actions Children’s TEAM took in reliance of this authorization before I revoked it.
● Once information is released to a third party according to this authorization, Children’s TEAM cannot prevent its re-disclosure.
● This authorization does not limit the ability of Children’s TEAM to use or disclose the client's health information as otherwise permitted by state and federal law.
NAME of legal parent/guardian/agent or independent client*
SIGNATURE of legal parent/guardian/agent or independent client*

Clear
Date*

MonthDayYear
Date
Expiration date upon the client’s 22nd birthday, unless an earlier date is provided here:

MonthDayYear
Date
Should be Empty: