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Get Sample HIPAA Authorization Form 2003-2022

SAMPLE HIPAA AUTHORIZATION FORM Disclaimer This document is provided solely for reference purposes. Your notice will not apply to actions taken by the requesting person/entity prior to the date they receive your written request to revoke authorization. 02/07/03 Page 1 of 2 Sample HIPAA Authorization Form Signature of Participant or Personal Representative Date Printed Name of Participant or Personal Representative Description of Personal Representative s Authority. Covered Entities under HIPAA are advised to refer to their Institution s Privacy Policy for specific requirements for the HIPAA Authorization* I give permission to Name of Institution to use the following protected health information and/or disclose the following protected health information to Name s of entity to receive information Information to be disclosed check all that apply Medical Records Treatment Records Diagnostic Records Other This protected health information is being used or disclosed for the following purposes This authorization expires specify 1 date or 2 event that relates to the purpose of this use or disclosure. If the person or entity receiving this information is not a health care provider or health plan covered by federal privacy regulations the information described above may be disclosed to other individuals or institutions and no longer protected by these regulations. You may refuse to sign this authorization* Your refusal to sign will not affect your ability to obtain treatment or payment or your eligibility for benefits. You may inspect or copy the protected health information to be used or disclosed under your right to access is suspended until the clinical trial is completed* Finally you may revoke this authorization in writing at any time by sending written notification to Name of Privacy contact at office address. Covered Entities under HIPAA are advised to refer to their Institution s Privacy Policy for specific requirements for the HIPAA Authorization* I give permission to Name of Institution to use the following protected health information and/or disclose the following protected health information to Name s of entity to receive information Information to be disclosed check all that apply Medical Records Treatment Records Diagnostic Records Other This protected health information is being used or disclosed for the following purposes This authorization expires specify 1 date or 2 event that relates to the purpose of this use or disclosure. If the person or entity receiving this information is not a health care provider or health plan covered by federal privacy regulations the information described above may be disclosed to other individuals or institutions and no longer protected by these regulations. If the person or entity receiving this information is not a health care provider or health plan covered by federal privacy regulations the information described above may be disclosed to other individuals or institutions and no longer protected by these regulations. You may refuse to sign this authorization* Your refusal to sign will not affect your ability to obtain treatment or payment or your eligibility for benefits. .

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