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Get louisiana hipaa form 2015-2024

Documentation on the above Personal Representative has been obtained. Signature and Title of Agency Representative HIPAA 402P Page 1 of 2 Issued 4/14/03 Revised 09/17/2013 Important Information about Authorization We may need your authorization to use disclose or obtain your health information for some of our services. Authorization to Release or Obtain Health Information including paper oral and electronic information Request Date Name Mailing Address Date of Birth City/State/Zip Medicaid or Social Security I authorize Name Relationship Telephone Number TO RELEASE Information TO OR TO OBTAIN Information FROM Place an X in the box that indicates if the information is being released OR requested* The Purpose of this Authorization is indicated in the box es below. Place an X in the box es that apply. Further Medical Care Personal Legal Investigation or Action Changing Physicians Research related treatment Creating health information for disclosure to a third party. Other Specify I authorize the release of the following protected health information* Entire Record Prescriptions X-ray Reports Medical History Examination Reports Surgical Reports Treatment or Tests Immunizations Hospital Records including Reports Laboratory Reports MR/DD Records Other In compliance with state and/or federal laws which require special permission to release otherwise privileged information please release the following records. Alcoholism Drug Abuse Mental Health Vocational Rehabilitation HIV AIDS Sexually Transmitted Diseases Genetics Psychotherapy Notes Other This authorization shall expire on date or event and is needed for the period beginning and ending. I understand that if I do not specify an expiration date this authorization will expire six 6 months from the date on which it was signed* I acknowledge that I have read both pages 1 and 2 of this form* Signature of Individual or Personal Representative Authorized by Law Date Signature of Witness If signed with an X or mark For DHH Use When Requesting Records I am authorized to receive this disclosure. You do not have to sign this form* If you agree to sign this authorization to release or obtain information you will be given a signed copy of the form* A separate signed authorization form is required for the use and disclosure of health information for Employment-related determinations by an employer Research purposes unrelated to your treatment When required by law or policy DHH may only obtain use and disclose your health information if the required written authorization includes all the required elements of a valid authorization* receiving treatment services or payment for health care services. If your authorization is required by law or policy DHH will use and disclose your health information as you have authorized on the signed You may be required to sign an authorization before receiving research-related treatment. information for disclosure to a third party. Example In a juvenile court proceeding where a parent is required to obtain a psychological evaluation on their minor child by DHH the parent may be required to sign an authorization to release the evaluation report but not the psychotherapy notes to DHH.

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