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HIPAA Privacy Authorization Form
Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act --- 45 CFR Parts 160 and 164)
Employee Information: TO BE COMPLETED BY EMPLOYEE OR PATIENT
Employee Name
Employee ID#
Patient Information
TO BE COMPLETED BY EMPLOYEE OR PATIENT
Patient Name
Date of Birth
MonthDayYear
Date
Case/Record/Other ID Number and Identify Type
1. I1, (the patient or representative) hereby authorize and request the Health Care Provider noted below (and its agents) to release my protected health information (PHI) to : ABC Company for purposes of certifying my serious health condition under Federal and state FMLA and other leave laws
Health Care Provider: TO BE COMPLETE BY EMPLOYEE OR PATIENT
Printed Name of Health Care Provider
Type of Practice/Medical Specialty
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Telephone Number
Please enter a valid phone number.
Printed Name of Health Care Provider
Fax Number
E-mail address
example@example.com
3. Authorization for release of PHI related to my serious health condition for the period of health care (check as appropriate)
from (date) ____________ to (date) _______________ ORall past, present and future periods; ORall records relating to:____________ from (date) ____________- to (date) ____________.
from (date) Date to (date) Date OR
all records relating to: Date from (date) Date - to(date) Date .
4. I hereby authorize the release of PHI as follows:
records relating to mental health care, communicable diseases, HIV or AIDS, and treatment of alcohol/drug abuse) related to the serious health condition. ORmy health record related to the serious health condition with the exception of the following (check as appropriate):Mental health recordsAlcohol/drug abuse treatmentCommunicable diseases (including HIV and AIDS)Other (please specify):
5. I authorize the medical information to be used by ABC Company personnel (and its agents) responsible for determining eligibility for federal and state FMLA and other leave laws or responsible for the audit or facilitation the evaluation or effectiveness of the Company’s leave laws (such as IT personnel).6. I understand that I am entitled to a copy of ABC COMPANY’s Notice of Privacy Practices. I can access a copy of the Notice of Privacy Practices from the website abccompany.com/privacypractices.html or from ABC Company's office directly.
Certification and Acknowledgement: I certify that I am the person (or the personal representative of the person) designated in Part 1. I agree that my individually identifiable health information described in Parts 3 and 4, and held by the person or entity listed in Part 2, may be disclosed to the person or entity listed in Part 5 for the purpose(s) designated in Part 6. I understand that, if the information to be disclosed is needed by a health care plan in order to determine my eligibility for plan benefits; or is needed by ABC Company to consider me for medical, sick or other leave; or to consider my eligibility or claim for short- or long-term disability or life insurance coverage or benefits, workers’ compensation benefits, or similar fringe benefits; or to consider me for employment or continued employment, my failure to provide this Authorization may prevent me from receiving the benefit or leave, or preclude me from being considered for employment or continued employment. I understand that I have the right to revoke this Authorization, in writing, at any time, by sending the revocation to the person or entity who received the Authorization, and that the revocation will be effective except to the extent that the person or entity releasing the information has already taken action in reliance on my Authorization. I understand that, once disclosed, it is possible that the health information may be further disclosed by the recipient and no longer subject to protection under international, federal, state, or local privacy rules. I have received a copy of my signed Authorization.
Person to Release Information To
FMLA/SPF Coordinator
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Phone
Please enter a valid phone number.
Fax
E-mail
example@example.com
Signature of Patient or Personal Representative
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Attestation: I understand the nature of this authorization.
Signature of Patient or Personal Representative
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Date
MonthDayYear
Date
Print Name
If this authorization is signed by a personal representative of the above-name patient, the personal representative must describe his or her authority to act:
Signature of Witness
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Date
MonthDayYear
Date
Signature of Witness
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Date
MonthDayYear
Date
* Witnesses only need if ABC Company requests witnesses as required by law
Should be Empty:

HIPAA Privacy Authorization Form