HIPAA Privacy Authorization Form

of of name

Name *

First

Last

Phone *

Email *

This authorization for release of PHI covers the period of healthcare (check one) *

• All past, present, and future periods
• Date Range (define below)

From / To Date

I hereby authorize the release of PHI as follows (check one) *

• I authorize the release of my complete health record (including records relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse).
• I authorize the release of my complete health record with the exception of the following information: Mental health records, Communicable diseases (including HIV and AIDS), Alcohol/drug abuse treatment, Other (specify below)

Other - PHI

Printed name of patient *

First

Last

Representation

• I am a personal representative of this member

Representative's Name

Relationship to member

Next: Signature