Friday, February 18, 2011

Hippa Form

Authorization for Use of Protected Health Information (Hippa Release) Page 1 of 2

Name of Hospital/Doctor: _________________________________________________

Hospital/Doctor Address: ______________________________________________________

Patient Name: Phone Number:

Date of Birth: Patient Record # (or SS #):


1. I authorize the above medical facility to disclose my health information specific to the following date or time period: To .

2. Name and address of individual or entity authorized to receive my health information:

3. The purpose for which disclosure is to be made: for use in a legal proceeding.

4. Information to be disclosed (check all applicable):

__Abstract __History and Physical Exam __Operative Report
__Admission Summary __Consultation __Laboratory Report
__Pathology Report __Radiology Reports
__EKG __Emergency Dept. Record __Discharge Summary
__ Entire Medical Record __Other:____________

5. To the extent applicable, I understand that my medical record may contain information that is considered sensitive under law. My check marks below indicate that I do not permit information of this time, if it exists, to be released. I understand that if I do not check the box, the above medical provider will release such information about me if it exists, including all healthcare information inclusive of alcohol, drug abuse, HIV testing, psychiatric notes, venereal disease and/or other sensitive related information.

__HIV/AIDS infection __Sexually TransmittedDiseases
__Mental/Psychiatric Health __Treatment for Alcohol And/or Drug Abuse

6. I understand that my records are protected under the federal privacy laws and regulations and under the general laws of the state of Massachusetts, and cannot be disclosed without by written consent except as otherwise specifically provided by law.

7. I understand that if the persons or entities that receive the information is not a healthcare provider or health plan covered by federal privacy regulations, the information described above may be disclosed and is no longer protected by those regulations. Therefore I release the above Hospital, Doctor or healthcare facility, its employees and my physicians from all liability arising from this disclosure of my health information.

8. It is my understanding that this authorization will expire 90 days from the day signed below. I understand that I may revoke this authorization by notifying, in writing, at any time. I understand that any previously disclosed information would not be subject to my revocation request.

Page 2 of 2

9. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment for my eligibility for benefits, unless otherwise described in the space provided here_________________________________


This form must be completed in full before signing.

________________________________ _______ ___________________________
(or Legal Representative) Date

____________________________ _____________________
Print Name of Legal Representative Relationship to Patient
(if applicable)

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