AUTHORIZATION FOR RELEASE OF INFORMATION Section A: Must be completed for all authorizations I hereby authorize the use

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Authorization For Release Of Information Section A Must Be Completed For All Authorizations I Hereby Authorize The Use 1 (58.33 KiB) Viewed 46 times

AUTHORIZATION FOR RELEASE OF INFORMATION Section A: Must be completed for all authorizations I hereby authorize the use or disclosure of my individually identifiable health information as described below. I understand that this authorization is voluntary. I understand that if the organization authorized to receive the information is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations ID Number Person/organizations providing information: Persons/organizations receiving information: Patient name: Specific description of information (including from and to datels)]: authorization. Section B: Must be completed only if a health plan or a heath care provider has requested the 1. The health plan or health care provider must complete the following a. What is the purpose of the use or disclosure? b. Will the health plan or health care provider requesting the authorization receive financial or in-kind compensation in exchange for using or disclosing the health information described above? YONO 2. The patient or the patient's representative must read and initial the following statements: 1. I understand that my health care and the payment for my health care will not be affected if I do not sign this Initials b. I understand that I may see and copy the information described on this form if I ask for it, and that I get a copy of this form after I sign it. Initials form. Section C: Must be completed for all authorizations. The patient or the patient's representative must read and initial the following statements: 1. I understand that this authorization will expire on (DD/MM/YR Initials: 2. I understand that I may revoke this authorization at any time by notifying the providing organization in writing. but if I do not it will not have any effect on any actions they took before they received the revocation. Initials 3. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules Initials Date Signature of patient or patient's representative (Form MUST be completed before signing) Printed name of patient's representative Relationship to the patient: "YOU MAY REFUSE TO SIGN THIS AUTHORIZATION You may not use this form to release information for treatment or payment except when the information to be released is psychotherapy notes or certain research information