HIPAA Authorization

Release of Protected Health Information

Consent for release of protected health information to family members or persons involved in your care.

About This Form

Many of our patients allow family members such as their parent(s), grandparents, guardians, or others to call and discuss their medical/billing information, request prescriptions; medical information, medical records and results of tests also pick up forms, etc. Under the requirements of HIPAA, we are not permitted to release this information to anyone without the patient's consent. If you wish to have any of your medical information released to family members or friends, you must sign this form.

Authorized Family Members / Persons

I consent to disclosure of protected health information about me to the following family member(s) or person(s) involved in my care or payment for my care.

Name

Relationship

Information to Disclose

Check all that may apply:

All my medical information

Information necessary to schedule appointments for me

Lab or test results

Information necessary to help my family member(s) take care of me

Information necessary to bill for or submit claims for care provided to me to government or private insurance payers

Acknowledgment

I understand I must sign a separate authorization form releasing copies of my medical record to another individual.
I understand I have the right to revoke my permission at any time except where HKD Outreach PC has already made disclosures in reliance upon this request. I understand this permission remains in effect until the time I revoke in writing.

Signature of Patient / Guardian *

Date *