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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 C. F*R* Parts 160 and 164 I authorize healthcare provider to use and disclose the protected health information described below to individual seeking the information. 2. Effective Period This authorization for release of information covers the period of healthcare from OR b. all past present and future periods. 3. Extent of Authorization a* I authorize the release of my complete health record including records relating to mental healthcare communicable diseases HIV or AIDS and treatment of alcohol or drug abuse. of the following information Mental health records Communicable diseases including HIV and AIDS Alcohol/drug abuse treatment Other please specify 4. This medical information may be used by the person I authorize to receive this information for medical treatment or consultation billing or claims payment or other purposes as I may direct. or event at which time this authorization expires. 6. I understand that I have the right to revoke this authorization in writing at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim* benefits will not be conditioned on whether I sign this authorization* federal or state law. Signature of patient or personal representative Printed name of patient or personal representative and his or her relationship to patient Date. F*R* Parts 160 and 164 I authorize healthcare provider to use and disclose the protected health information described below to individual seeking the information. 2. Effective Period This authorization for release of information covers the period of healthcare from OR b. 2. Effective Period This authorization for release of information covers the period of healthcare from OR b. all past present and future periods. 3. Extent of Authorization a* I authorize the release of my complete health record including records relating to mental healthcare communicable diseases HIV or AIDS and treatment of alcohol or drug abuse. all past present and future periods. 3. Extent of Authorization a* I authorize the release of my complete health record including records relating to mental healthcare communicable diseases HIV or AIDS and treatment of alcohol or drug abuse. of the following information Mental health records Communicable diseases including HIV and AIDS Alcohol/drug abuse treatment Other please specify 4. of the following information Mental health records Communicable diseases including HIV and AIDS Alcohol/drug abuse treatment Other please specify 4. This medical information may be used by the person I authorize to receive this information for medical treatment or consultation billing or claims payment or other purposes as I may direct. .

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