HIPAA Right of Access Form for Family Member/Friend

HIPAA Right of Access Form for Family Member/Friend
I, *, direct my health care and medical services providers and payers to disclose and release my protected health information described below to:
Name*
Relationship:*
Contact information:*
Health Information to be disclosed upon the request of the person named above -- (Check either A or B):*

A. Disclose my complete health record (including but not limited to diagnoses, lab tests, prognosis, treatment, and billing, for all conditions)B. Disclose my health record, as above, BUT do not disclose the following (check as appropriate):
*

Mental health recordsCommunicable diseases (including HIV & AIDS)Alcohol/drug abuse treatmentOther (please specify):
Form of Disclosure (unless another format is mutually agreed upon between my provider and designee):*

An electronic record or access through an online portalHard copy
This authorization shall be effective until (Check one):*

All past, present, and future periods, ORDate or Event:
unless I revoke it. (NOTE: You may revoke this authorization in writing at any time by notifying your health care providers, preferably in writing.) *
Name of the Individual Giving this Authorization*
Date of Birth*

MonthDayYear
Date
Signature of the Individual Giving this Authorization

Clear
Date

MonthDayYear
Date
Note: HIPAA Authority for Right of Access: 45 C.F.R. § 164.524 Resource provided by the ABA Commission on Law and Aging | www.americanbar.org/aging
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