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Authorization For The Use And/Or Disclosure Of Protected Health Information
I authorize the use and/or disclosure of my protected health information as described below: 1. My authorization applies to the information described below. Only this information may be used and/or disclosed pursuant to this authorization (please include period of time requested): From: __________ To: __________ Entire medical record (no psychiatric, alcohol, or substance abuse or HIV/AIDS included) Lab Results X-Ray Results Psychiatric records Alcohol or substance abuse records HIV/AIDS related records Other, specify ____________________________________________________________________ 2. I authorize Strauss Clinics to make the authorized use and/or disclosure of my protected health information: 3. I authorize the following persons to receive my protected health information: (at request of individual if left blank) 4. I understand that, if my protected health information is disclosed to someone who is not required to comply with federal privacy protection regulations, then such information may be re-disclosed and would no longer be protected. 5. I understand that I have a right to revoke this authorization at any time. My revocation must be in writing to Strauss Clinics. I am aware that my revocation is not effective to the extent that the persons I have authorized to use and/or disclose my protected health information have acted in reliance upon this authorization. 6. This authorization expires upon _________________________. (6 months from date signed if left blank) 7. I understand that I do not have to sign this authorization and that my refusal to sign will not affect my abilities to obtain treatment from Strauss Clinics, nor will it affect my eligibility for benefits. 8. My protected health information will be used or disclosed upon request for the following purposes Use in future medical care Use in insurance claim processing Use in legal claim processing Use in external quality/utilization review Other, specify ____________________________________________________________________ 9. I understand that I have a right to inspect and copy my own protected health information to be used or disclosed, (in accordance with the requirements of the federal privacy protection regulations found under 45 C.F.R. §164.524). I certify that I have received a copy of the authorization. Patient / Guardian Signature DOB Social Security #
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