Form#4 Patient Authorization for Use or Disclosure of Protected Health Information

Patient Authorization for Use Or Disclosure of Protected Health Information
I, your name* , born on date of birth* hereby authorize the use or disclosure of medical and/or educational protected health information as described below:
Grace Medical Home is authorized to use or disclose information about me. The following person (persons) may receive disclosure of my protected health information including my condition, treatment, diagnosis, medications and appointments:
1. Name
Phone Number

Area CodePhone Number
This Protected Health Information would be disclosed as described in our privacy policies for the maintenance and delivery of care. Unless you sign here, no information about alcohol/substance abuse, HIV/AIDS, or Mental Health will be disclosed.
YES, disclose this information to this person:
NO, DO NOT disclose this information to this person:
2. Name
Phone Number

Area CodePhone Number
This Protected Health Information would be disclosed as described in our privacy policies for the maintenance and delivery of care. Unless you sign here, no information about alcohol/substance abuse, HIV/AIDS, or Mental Health will be disclosed.
YES, disclose this information to this person:
NO, DO NOT disclose this information to this person:
3. Name
Phone Number

Area CodePhone Number
This Protected Health Information would be disclosed as described in our privacy policies for the maintenance and delivery of care. Unless you sign here, no information about alcohol/substance abuse, HIV/AIDS, or Mental Health will be disclosed.
YES, disclose this information to this person:
NO, DO NOT disclose this information to this person:
I understand that I do not need to consent to the release of this information. I will not be denied treatment if I do not authorize the requested use and disclosure of this protected health information. By signing this release, I give my consent willingly as specified above.

This Authorization shall be in force and effect until revoked, at which time this Authorization to use or disclose my Protected Health information shall expire.

I understand that I have the right to revoke this Authorization, in writing, at any time by sending such written notification to Privacy Office at Grace Medical Home, 1417 E. Concord Street, Orlando, FL 32803. I understand that a revocation is not effective to the extent that Grace Medical Home has relied on the use or disclosure of the Protected Health Information.

I understand that information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law.

I understand that I have the right to:

· Inspect or copy the Protected Health Information to be used or disclosed as permitted under federal law (or state law to the extent the state law provides greater access rights).

· Refuse to sign this Authorization

I have reviewed the information above, and any questions I may have had about this form have been answered to my satisfaction. I have been offered and/or given a copy of this form.
Signature (patient over 18 years of age)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature of Parent/Guardian
Relationship to Patient
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Patient Authorization for Use Or Disclosure of Protected Health Information