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HIPAA AUTHORIZATION FOR USE OR DISCLOSURE OF

HEALTH INFORMATION

Date:

THE PATIENT. This form is for use when such authorization is required and complies

with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy

Standards.

Patient's Name:

Social Security Number

Driver License number:

ILAUTHORIZATION. authorize Michael They, PMHNP-BC (“Authorized Party") to use or

disclose the following: (check one)

@Ariof my medicat-retated information,

Ill_DISCLOSURE. The Authorized Party has my authorization to disclose Medical Records

to: (check one) Joel ReBles

DOT (2IS3TY

IV.PURPOSE. The reason for this authorization is:

V.ACKNOWLEDGMENT OF RIGHTS.

understand that I have the right to revoke this authorization, in writing and at any time, except

where uses or disclosures have already been made based upon my original permission. might

not be able to revoke this authorization if its purpose was to obtain insurance.

understand that uses and disclosures already made based upon my original permission cannot

be taken back

understand that itis possible that Medical Records and information used or disclosed with my

permission may be re-disclosed by a recipient and no longer protected by the HIPAA Privacy

Standards.

understand that treatment by any party may not be conditioned upon my signing of this,

authorization (unless treatment is sought only to create Medical Records for a third party or to

take part in a research study) and that may have the right to refuse to sign this authorization.

wil receive a copy of this authorization after jnave signed it A copy of tis authorization is as

valid asthe orginal

Signature of Patient: Date: h A

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