AUTHORIZATION FOR USE AND DISCLOSURE OF INFORMATION

AUTHORIZATION FOR USE AND DISCLOSURE OF INFORMATION
Location of Services
LEGAL NAME

First NameLast Name
DATE OF BIRTH

MonthDayYear
Date
I hereby authorize the use or disclosures 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 a health care provider, the released information may be re-disclosed and may no longer be protected by federal privacy regulations.
PERSON/ORGANIZATION AUTHORIZED TO RELEASE THE INFORMATION
Name and address of person/organization authorized to RELEASE the information:

Name

Address

CityState / Province

Postal / Zip Code
Phone number of person/organization authorized to RELEASE the information:
Please enter a valid phone number.Format: (000) 000-0000.
Fax number of person/organization authorize to RELEASE the information:
Please enter a valid phone number.Format: (000) 000-0000.
PERSON/ORGANIZATION AUTHORIZED TO RECEIVE THE INFORMATION
Name and address of person/organization authorized to RECEIVE the information:

Name

Address

CityState / Province

Postal / Zip Code
Phone number of person authorized to RECEIVE the information:
Please enter a valid phone number.Format: (000) 000-0000.
Fax number of person authorized to RECEIVE the information:
Please enter a valid phone number.Format: (000) 000-0000.
DESCRIPTION OF INDIVIDUALLY IDENTIFIABLE INFORMATION TO BE RELEASED/RECEIVED (CHECK ALL THAT APPLY):
Date Range of Medical Records to Be Released/Received:
Date Range of Psychotherapy Notes to Be Released/Received:
Other Lab Reports to Be Released/Received:
Other Information to Be Released/Received:
The above information will be used for the following purpose(s):
Other
The patient or the patient's legal representative must read and initial the following statments:
1. I understand that the information in my health record may include information relating to sexually transmitted infections (STIs), acquired immunodeficiency syndrom (AIDS) or my human immunodeficiency virus HIV) status. It may also include information about mental health services and substance use treatment.
2. I understand that i may revoke this authorization at any time by notifying the providing organization in writing, but if I do, it will not have an effect on any actions taken before the organization received the revocation. If I fail to speciy an expiration date this release will expire 12 months after the date signed below and without further action by your or PIHC.
EXPIRATION DATE (OPTIONAL- if you fail to specify an expiration date this release will expire 12 months after the date signed below and without further action by you or PIHC)

MonthDayYear
Date
3. I understand that authorizing the disclosure of health information is voluntary. This release of information demonstrates compliance with the HIPAA Standards for Privacy of Individually Identifiable Health Information Privacy Standards, 45 CFR 160 and 164, 42 CFR Pt 2 and all federal regulations and interpretive guidelines promulgated thereunder. I understand any disclosure of information carries with it the potential for an unauthorized re - disclosure and the information may not be protected by federal confidentiality rules.
NOTICE TO PATENT: The patient or the patient's legal representative may inspect and/or copy the protected health information to be disclosed in accordance with PIHC’s access policies. PIHC does not limit its right to make a use or disclosure of your information that is required by law or permitted to avert a serious threat to the health or safety to the public.

YOU MAY REFUSE TO SIGN THIS AUTHORIZATION

THE PROGRAM WILL NOT CONDITION TREATMENT OR PAYMENT ON THE PROVISION OF THIS AUTHORIZATION

REVISED 6/7/2023
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

AUTHORIZATION FOR USE AND DISCLOSURE OF INFORMATION

PERSON/ORGANIZATION AUTHORIZED TO RELEASE THE INFORMATION

PERSON/ORGANIZATION AUTHORIZED TO RECEIVE THE INFORMATION

The patient or the patient's legal representative must read and initial the following statments: