AUTHORIZATION FOR USE AND DISCLOSURE OF HEALTH INFORMATION 2026

AUTHORIZATION FOR USE AND DISCLOSURE OF HEALTH INFORMATION

HIPAA 45 CFR §§ 160, 184|42 CFR Part 2 (as amended effective February 16, 2024)
Location of Services
LEGAL NAME

First Name, Middle InitialLast Name
DATE OF BIRTH

MonthDayYear
Date
MRN #
PATIENT STATUS:
If minor, Legal Representative Name and Relationship
Releasing and Receiving Parties
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 INFORMATION TO BE RELEASED
Check all that apply

Other
Enter date range (if applicable)
List other lab reports
Describe scope of verbal communication
Note: Psychotherapy notes require a separate authorization form. Please ask PIHC staff for Form ROI – PSY
PURPOSE OF THIS RELEASE
PLEASE READ AND INITIAL EACH STATEMENT BELOW

Each of the following statements explains your rights and what you are agreeing to. Please read each one carefully and write your initials in the space provide.
1. I understand that the information in my health record may include information about sexually transmitted infections (STI), HIV/AIDS status, mental health services and/or substance use treatment.
2. I understand that I can cancel (revoke) this authorization at any time by notifying PIHC in writing. Canceling it will not undo any disclosures that have already been made.
EXPIRATION DATE (OPTIONAL- If I leave this blank this authorization will automatically expire 12 months from the date I sign below.

MonthDayYear
Date
3. I understand that signing this authorization is completely voluntary. This form complies with HIPAA (CFR Parts 160 and 164) and where applicable, 42 CFR Part(as amended effective February 16, 2024). Records protected under 42 CFR Part 2may not be re – disclosed except as permitted by federal law. Information shared with recipients who are not covered by HIPAA or 42 CFR Part 2 may not carry the same federal privacy protections and could potentially be further disclosed.
4.I understand that PIHC will share only the minimum amount of informationnecessary to accomplish the purpose of this authorization..
IMPORTANT NOTICE TO PATIENT

Right to Refuse: You have the right to refuse to sign this authorization. Your treatment, payment, enrollment and eligibility for benefits at PIHC will not be affected if you choose not to sign.

Right to inspect or copy: You or your legal representative may inspect and/or copy the health information to be disclosed, in accordance with PIHC’s access policies.

Legally required disclosures: PIHC may disclose your information when required by law or to prevent a serious threat to health or safety.

Minors: If you are a minor who has consented to your own HIV?STI care under Georga law (O.C.G.A § 31-17-7) you – not your parent or guardian – are the person who controls this authorization.
Signature of Patient/Legal Representative
If Legal Representative - Relationship to Patient
Authority:
Date

MonthDayYear
Date
YOU MAY REFUSE TO SIGN THIS AUTHORIZATION

PIHC WILL NOT CONDITION YOUR TREATMENT OR PAYMENT ON WHETHER YOU SIGN THIS AUTHORIZATION
Name/Credentials of PIHC Staff
Signature of PIHC Staff
Date Reviewed/Signed by PIHC Staff
Should be Empty:

AUTHORIZATION FOR USE AND DISCLOSURE OF HEALTH INFORMATION

Releasing and Receiving Parties

PERSON/ORGANIZATION AUTHORIZED TO RECEIVE THE INFORMATION

DESCRIPTION OF INFORMATION TO BE RELEASED

YOU MAY REFUSE TO SIGN THIS AUTHORIZATION