Authorization to Disclose Health Information

This Package Contains:
1. Instructions and Checklist

2. Information regarding the Authorization; and

3. the Authorization.

Instructions & Checklist

Authorization to Disclose Health Information

 This package contains:

(1) Instructions and Checklist for the Authorization to Disclose Health Information (the “Authorization”);

(2) Information regarding the Authorization; and

(3) the Authorization.

• Complete the form, including any requested information.

• The patient or the patient’s legal representative must sign and date the Authorization.

• This Authorization complies with the HIPAA Privacy Rules.

 Keep a copy of the Authorization for future reference.

 Laws vary from time to time and from state to state. This form is not intended to be and is not a substitute for legal advice. This form should only be a starting point for you and should not be used or signed before first consulting with an attorney to ensure that it addresses your particular situation. An attorney should be consulted before negotiating any document with another party.

 The purchase and use of these forms is subject to the “Disclaimers and Terms of Use” found at findlegalforms.com.

Information

Authorization to Disclose Health Information

Your health and medical information is considered sensitive and private and is afforded protection under the law. However, there are circumstances when you may want to provide this information to another individual or entity (e.g. insurance companies, employers, etc.). In those circumstances, you will generally sign an authorization to disclose health information. These authorizations can be quite broad or quite limited.

This form of Authorization to Disclose Health Information allows you the flexibility to determine what types of information are to be released and under what circumstances. In addition, this form complies with the HIPAA (Health Insurance Portability and Accountability Act) Privacy Rules

For more information on medical information privacy you can contact:

U.S. Department of Health and Human Services
Office of Civil Rights
200 Independence Avenue, S.W.
Washington, D.C., 20201
Phone: (866) 627-7748
Web: www.hhs.gov

States may have different laws relating to the release of information, so you should become familiar with the laws of your state before using this form. In addition, before using this form you should consult with your attorney or physician to ensure that it addresses your specific situation.