HIPAA - Jeanette Keller
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 .
Address: Social Security No.:
Persons/organizations providing the information:
Persons/organizations receiving the information:
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:
Printed Name of patient's representative:
Relationship to the patient: _________________________
Leave this empty:
Your legal name
If you have questions about the contents of this document, you can email the document owner.
Document Name: HIPAA - Jeanette Keller
Agree & Sign