Athletic Evolution Physical Therapy

HIPAA Privacy Authorization Form


**Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)**

  1. I, authorize all medical service sources and health care providers to use and/or disclose the protected health information (PHI) described below to my Personal Representative(s) named as follows:  
  2. This authorization for release of PHI covers the period of healthcare (check one)
    1. from  to  
  3. I hereby authorize the release of PHI as follows (check one)
    1. 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).
      • Mental health records
      • Communicable diseases (including HIV and AIDS)
      • Alcohol/drug abuse treatment
      • Other (please specify):  
  4. This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.
  5. This authorization to release information to my Personal Representative will automatically expire two (2) years following the termination of my enrollment with the Health Plan.
  6. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
  7. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.
  8. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.

Printed name of patient or personal representative and relationship to Member:

Date:

Signature of Member or Personal Representative (below):

Leave this empty:

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Signature Certificate
Document name: HIPAA Privacy Authorization Form
lock iconUnique Document ID: 5c5e4a2f774a105f60176b3a4c4f99675b01a7b5
Timestamp Audit
November 18, 2022 12:32 pm ESTHIPAA Privacy Authorization Form Uploaded by Liam Sullivan - [email protected] IP 73.114.240.59