HIPAA COMPLIANT AUTHORIZATION FORM

AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby authorize the use of disclosure of my individually identifiable health information as described below.

I understand that this authorization is voluntary and is valid beginning with the date signed below and remains valid for one (1) year. 

I understand that if the organization authorized to receive the information is not a health plan or healthcare provider, the released information may no longer be protected by Federal Privacy Reguilations.

I acknowledge that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by federal law.

I understand that my health record may include information pertaining to the treatment of drug and alcohol abuse, mental illness, acquire immunodeficiency syndrome (AIDS) or human immunodeficiency (HIV); sexually transmitted disease, tuberculosis or genetics. If you do not wish this information to be released, please initial DO NOT RELEASE .

Patient Name:

Address:
Social Security No.:

Specific description of information: _________________________

What is the purpose of the use or disclosure? Legal

The patient or the patient's representative must read and initial the following statements:

1. I understand that this authorization will expire on (DD/MM/YYYY)
   Initials
2. I understand that I may reveoke this authorization at any time by notifying the practice in writing, but if I do, it won't have any affect on any actions they took before they received the revocation. 
   Initials

Date:

Printed Name of patient's representative:

Relationship to the patient: _________________________

Leave this empty:

Your legal name

Please Confirm full name and signature.

Change fonts

• Draw Signature
  
• Type In Signature
  

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

Insert Signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Signature Certificate

Document name: HIPAA - Jeanette Keller

Unique Document ID: 4a533b3c056c108173f16c508a78a00f4a08459d

Build. Track. Sign Contracts.

Timestamp	Audit
June 30, 2020 6:17 pm GMT	HIPAA - Jeanette Keller Uploaded by David Rosenbaum - test@rosenbaumfirm.com IP 162.221.24.2
June 30, 2020 6:18 pm GMT	Jeanette Keller - jkeller@rosenbaumfirm.com added by David Rosenbaum - test@rosenbaumfirm.com as a CC'd Recipient Ip: 162.221.24.2

This audit trail report provides a detailed record of the online activity and events recorded for this document.

https://www.rosenbauminjuryfirm.com/

Audit Trail Serial# 78d6c7fb8d267494b06be0df1bcd121b