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HIPAA Authorization for Use and Disclosure Policy and Form

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This HIPAA Authorization for Use and Disclosure Policy and Form should be executed by an individual seeking the release and distribution of certain health records. The form states the individual’s purpose for this authorization of disclosure and distribution and further sets forth the time limit pertaining to the release and disclosure. This document includes a clause whereby by individual acknowledges that upon authorizing the release of the health information and records to the parties named in the form, such health information and records may no longer be federally protected.

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									This HIPAA Authorization for Use and Disclosure Policy and Form should be executed
by an individual seeking the release and distribution of certain health records. The form
states the individual’s purpose for this authorization of disclosure and distribution and
further sets forth the time limit pertaining to the release and disclosure. This document
includes a clause whereby by individual acknowledges that upon authorizing the release
of the health information and records to the parties named in the form, such health
information and records may no longer be federally protected.
                                                HIPAA Authorization for Use and Disclosure Policy Form



      HIPAA AUTHORIZATION FOR USE AND DISCLOSURE
                     POLICY FORM

TO:


       THE UNDERSIGNED HEREBY AUTHORIZES the use, disclosure and distribution of
the undersigned individual health information.

        THE PURPOSES OF PROVIDING this authorization for the disclosure and distribution
of the undersigned’s individual health information is for                                  and
such disclosure and distribution of the undersigned’s individual health information shall be used
for no other purpose or purposes.

       THE UNDERSIGNED HEREBY AUTHORIZES the release of the following health
information and or records of the undersigned to the party(s) as set out herein:

       (a) ___________________________________;

       (b) ___________________________________; and

       (c) ___________________________________.


        The release and disclosure of the health information and records set out above shall be for
the period commencing __________________ through to and including ______________.

THE UNDERSIGNED HEREBY AUTHORIZES THE RELEASE OF THE HEALTH
INFORMATION AND OR RECORDS TO THE FOLLOWING INDIVIDUALS AND/OR
ORGANIZATIONS OR GOVERNMENTAL AUTHORITIES:

   1. ________________________________________________________
       (include address and telephone number)


   2. ________________________________________________________
       (include address and telephone number)


   3. ________________________________________________________
       (include address and telephone number)


    THE UNDERSIGNED ACKNOWLEDGES THAT upon authorizing the release of the
health information and records to the parties named above, that such health information and
records may no longer be protected by the federal privacy regulations of the governing
jurisdiction.
                                              3


       THIS AUTHORIZATION shall expire on the ___ day of ______________, 2___.


       THE UNDERSIGNED SHALL HAVE THE RIGHT to revoke the authorization granted
herein at any time by providing written notice to whom this authorization is address to at the
following address ______________________.

       DATED this ____ day of ___________, 2_____.




Witness:                                          Signature
                                                                     4


								
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