HIPAA Release

Patient Authorization for Use and Disclosure of Protected Health Information
By signing, I authorize New Path Medical Center to use and/or disclose certain protected health information (PHI) about me to the following person:*
Type Name of who you give us permission to speak to about your care, appointments, etc.
This authorization permits New Path Medical Center to use and/or disclose the following individually indentifiable health information about me (specifically describe the information to be used or disclosed, such as date(s) of service, type of services, level of detail to be released, origin of information, etc.
The information will be used or disclosed for the following purpose:
If disclosure is requested by the patient, purpose may be listed as "at the request of the individual."
The purpose(s) is/are provided so that I can make an informed decision whether to allow release of the information. This authorization will expire on:
If no expiration, leave blank
I do not have to sign this authorization in order to receive treatment from New Path Medical Center. In fact, I have the right to refuse to sign this authorization. When my information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization. My written revocation must be submitted to the privacy office at:

New Path Medical Center, PO Box 1780, Columbia, KY 42728
Are there any limitations regarding what information can be released? Example: appointments only, etc.
If no limitations, leave blank
Signature of Patient or Legal Guardian*

Clear
Relationship to Patient*
Print Patient's Name*
Date*

MonthDayYear
Date
Print Name of Legal Guardian, if applicable
Patient/guardian must be provided with a signed copy of this authorization form.
Should be Empty:

Patient Authorization for Use and Disclosure of Protected Health Information