HIPAA - AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) COMPLIANT REQUEST FORM
Section A: This section must be completed for all Authorizations
This authorization will expire on the following: (Fill in the Date or the Event but not both.) Date: 12 months from the signature date Event:
Purpose of disclosure: This information will be used to settle or prosecute a personal injury claim on behalf of the patient.
Description of information to be used or disclosed
I understand that:
1. I may refuse to sign this authorization and that it is strictly voluntary.
2. My treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this authorization.
3. I may revoke this authorization at any time in writing, but if I do, it will not have any affect on any actions taken prior to receiving the revocation. Further details may be found in the Notice of Privacy Practices.
4. If the requester or receiver is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations and may be re disclosed.
5. I understand that I may see and obtain a copy the information described on this form, for a reasonable copy fee, if I ask for it.
6. I get a copy of this form after I sign it.
If yes, the health plan or health care provider must complete Section B, otherwise skip to Section C.
This information will be used to settle or prosecute a personal injury claim on behalf of the patient.
Section C: Signatures
I have read the above and authorize the disclosure of the protected health information as stated.
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