HIPAA Release Authorization Form

HIPAA Release Authorization Form

Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)
Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
age
1. I authorize __Binu Chacko MD PC, 366 N. Broadway, Suite PH-E1, Jericho, NY 11753__ to disclose the protected health information described below to (fill name of person/institution to send letter/record to):

First NameLast Name
Name of receiving Institution:
Address of receiving institution/provider:

Street Address/Institution name

Street Address Line 2

CityState / Province

Postal / Zip Code
Fax Number of receiving person:

Area CodePhone Number
2. Allowed Purpose of Disclosure of Information
Indicate the purpose of disclosure (e.g. For other treatment providers, for school/college accommodations, etc.)
3. Type of Medical Information to be disclosed

Other
4. Other Information allowed to be disclosed
5. This authorization is effective FROM:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Expires on (future date):

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate of Expiry
6. 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.

7. This authorization shall be in force and effective until __Date of Expiry (as indicated above), or when Terminated or Discharged from practice__, at which time this authorization expires.

8. I understand that I have the right to revoke this authorization, in writing, at any time prior to date of expiry. 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.

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

10. 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.
Signature of Patient/ Legal Representative:
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent or Legally Authorized Representative Information

(In case the patient is below the legal age of consent or unable to consent due to developmental disabilities)
Name of Patient/ Parent/or Guardian

First NameLast Name
Relationship to Patient
Should be Empty: