Authorization of use and Disclosure of PHI

Authorization of use and Disclosure of PHI
Information to be Used or Disclosed. The information covered by this authorization includes:
Purpose of the Disclosure:
Persons Authorized to Use or Disclose the Above Information:
Persons to Whom Information May Be Disclosed:
Expiration Date of Authorization
This authorization is effective through

Choose a date NO Expiration
Expiration

Month Day Year
Right to Terminate or Revoke Authorization

You may revoke or terminate this authorization by submitting a written revocation to our office. You should contact the HIPAA Compliance Officer to terminate this authorization.
Potential for Re-disclosure

Information that is disclosed under this authorization may be re-disclosed by the person or organization to which it is sent. The privacy of this information may not be protected under the Federal Privacy Rule depending on whom the information is disclosed to. Our practice will not condition treatment, payment, enrollment or eligibility for benefits on whether the individual signs this authorization.
I HAVE READ AND AGREE TO THE ABOVE STATEMENTS.
Name of Patient

First Name Middle Name Last Name
Patient E-mail
_______________________________________________________________________
Signature of Patient Date
_______________________________________________________________________
Patient Representative and Relationship (if applicable) Date
_______________________________________________________________________
Physician Signature Date
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Authorization of use and Disclosure of PHI

Expiration Date of Authorization

Right to Terminate or Revoke Authorization

Potential for Re-disclosure