Get MO HIPAA Privacy Authorization Form 2009-2024

HIPAA Privacy Authorization Form Authorization for use or disclosure of protected health information. Required by the Health Insurance Portability and Accountability Act 45 CFR Parts 160 and 164 Return to Missouri Attorney General s Office Attn Jodi Lehman PO Box 899 Jefferson City MO 65102 MISSOURI ATTORNEY GENERAL CHRIS KOSTER 573-751-3321 ago. mo. gov 1 I hereby authorize NAME OF HEALTH CARE PROVIDER protected health information described below to to use and/or disclose the. NAME OF INDIVIDUAL a to OR All past present and future periods communicable diseases HIV or AIDS and treatment of alcohol/drug abuse. b Mental health records Alcohol/drug abuse treatment Other 3 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. 4 This authorization shall be in force and effect until DATE OR EVENT at which time this authorization expires. 5 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* longer be protected by federal or state law. SIGNATURE OF PATIENT OR PERSONAL REPRESENTATIVE DATE PRINT NAME OF PATIENT OR PERSONAL REPRESENTATIVE RELATIONSHIP TO PATIENT APRIL 2009. mo. gov 1 I hereby authorize NAME OF HEALTH CARE PROVIDER protected health information described below to to use and/or disclose the. NAME OF INDIVIDUAL a to OR All past present and future periods communicable diseases HIV or AIDS and treatment of alcohol/drug abuse. NAME OF INDIVIDUAL a to OR All past present and future periods communicable diseases HIV or AIDS and treatment of alcohol/drug abuse. b Mental health records Alcohol/drug abuse treatment Other 3 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. b Mental health records Alcohol/drug abuse treatment Other 3 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. 4 This authorization shall be in force and effect until DATE OR EVENT at which time this authorization expires. 4 This authorization shall be in force and effect until DATE OR EVENT at which time this authorization expires. 5 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* longer be protected by federal or state law. .