Authorization to Release Information

HIPPA Privacy Authorization for Release of Information

Authorization for use of disclosure of protected health information (required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)
Client Name*

First NameLast Name
Client Date of Birth*

MonthDayYear
Date
Client Phone Number*
Please enter a valid phone number.
Client Email Address*
example@example.com
I authorize the following person/facility to RELEASE protected health information:*
Example: In Him Christian Wellness
Address of Person/Facility Releasing Health Information:
Email Address of Person/Facility Releasing Health Information:
example@example.com
I authorize the following person/facility to RECEIVE protected health information:*
Address of Person/Facility Receiving Health Information:
Receiver's Email Address:
example@example.com
Delivery Method (please fill out bottom portion accordingly):*

Postal MailClient Pick UpEncrypted EmailInformation exchanged via phone callFax (confidentiality is not guarenteed with this method)Other
Pickup Office Location if applicable
Check to acknowledge your understanding of this Authorization:*

This information may be used by the person or organization I authorize to receive this information for medical treatment or consultation, billing or claims payment or assistance, or other purposes as I may direct.I have questions and will contact IHCW.

Expiration and Revocation:

If the health information to be disclosed contains HIV/AIDS or substance abuse treatment records, this Authorization expires within 60 days. Otherwise, you may select a date of expiration.
EXPIRATION OF AUTHORIZATION
Unless otherwise revoked, this Authorization expires insert applicable date or event. If no date is indicated, the Authorization will expire 12 months after the date of my signing this form.
NOTICE
In Him Christian Wellness (IHCW) and many other organizations and individuals such as physicians, hospitals, and health care plans are required by law to keep your health information confidential. If you have authorized the disclosure of your health information to someone who is not legally required to keep it confidential, it may no longer be protected by state or federal confidentiality laws.

YOUR RIGHTS
This Authorization to release health information is voluntary. Treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this Authorization, except in the following cases: (1) to conduct research-related treatment, (2) to obtain information in connection with eligibility or enrollment in a health plan, (3) to determine an entity's obligation to pay a full or partial claim, or (4) to create health information to provide to a third party.

The information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer can be protected by HIPPA upon its release to the recipient.

This Authorization may be revoked at any time. The revocation must be in writing, signed by you or your patient representative, and delivered to the IHCW site where you have received care. The revocation will take effect when IHCW receives it, except to the extent IHCW or others have already relied on it.

You have the right to inspect and copy the information to be used or disclosed pursuant to this Authorization.
I have read the above and authorize the disclosure of protected health information as a stated:*

Clear
Printed Name:*
Relationship to Patient*
Should be Empty:

HIPPA Privacy Authorization for Release of Information

Disclosure Agreement

Expiration and Revocation: