(Name and Address of Provider)
AUTHORIZATION

FOR THE RELEASE OF PROTECTED HEALTH INFORMATION

This Authorization authorizes the release of Protected Health Information pursuant to 45 CFR Parts 160 and 164.

1. The undersigned authorizes the above-named provider ("Provider") to release the following information: (describe specifically)

2. The information may be disclosed by employees or business associates of (Provider).

3. The information may be disclosed to: _______________________________(insert name or other specific identification of the persons or entities to which the disclosure will be made)

4. The disclosure may be made for the following purpose __________________________________(describe specifically. If disclosure is at patient's request, “Patient request” will suffice)

5. This authorization will expire on (date) _________________________. (or when - describe occurrence).

6. I acknowledge: (i) that I have the right to revoke the authorization at any time, and (ii) that I understand that once the information is disclosed, it may no longer be protected by federal privacy law.

You may revoke this authorization only in a writing sent by certified mail to (the Provider) at the address above. The revocation will be effective only upon receipt, except (1) to the extent (the Provider) has acted in reliance on the authorization, or (2) the authorization was obtained as a condition of obtaining insurance coverage and the insurer wishes to use to the protected health information to lawfully contest a claim.

7. I understand that treatment by (the Provider) is not conditioned on my signing this authorization, although exceptions will be made for (a) research-related treatment, (b) for treatment the purpose of which is creating protected health information for a third party, such as pre-employment physicals, and (c) except for psychotherapy notes, for health plans who condition enrollment or on an authorization requested prior to enrollment, or where payment is conditioned on an authorization to use PHI to determine payment.

8. If this authorization is for a marketing use or disclosure of my information, (the Provider):

8.1 [ ] will be remunerated by a third party.

8.2 [ ] will not be remunerated by a third party.

Date:______________________________

Signed by___________________________________

Print Patient's Name:___________________________

If person signing is other than patient, state authority under which signature is made:

(The patient must be given a copy of the authorization.)