Jun 11

Health Insurance Portability and Accountability Act(HIPAA) form is a form which safeguards your personal privacy.

Below is a great example of what an HIPAA form consists of.

Health Insurance Portability and Accountability Act(HIPAA) Form for Use or Disclosure of Protected Health Information.

1. Authorization
I authorize ________________________________ (Healthcare Provider) to use and disclose the protected health information described below to _______________________________ (individual seeking the information).

2. Effective Period
This authorization for release of information covers the period of healthcare from:
a. ______________ to ______________.

OR

b. □ all past, present, and future periods.

3. Extent of Authorization
a. □ I authorize the release of my complete health record (including records relating to mental healthcare, and treatment of alcohol or drug abuse).

OR
b. □ I authorize the release of my complete health record with the exception of the following information:

□ Mental health records
□ Alcohol/drug abuse treatment
□ Other (please specify): _______________________________________________

4. This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.

5. This authorization shall be in force and effect until ___________________ (date or event), at which time this authorization expires.

6. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

7. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.

8. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.

X________________________________________
Signature of patient or personal representative

X_________________________________________
Printed name of patient or personal representative and his or her relationship to patient

___________
Date

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