HIPAA Authorization for Release of Health Information

# HIPAA Authorization for Release of Health Information This Authorization is provided in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. § 164.508, and authorizes the use or disclosure of protected health information (PHI) as described below. You have the right to revoke this Authorization at any time. Completion of this form is voluntary; however, failure to complete it may prevent the release of information you have requested. --- ## Section 1 — Patient Identification **Patient Name:** ___________ **Date of Birth:** ___________ **Address:** ___________ **Phone Number:** ___________ --- ## Section 2 — Information to Be Disclosed **Describe the health information to be used or disclosed** (be as specific as possible, e.g., dates of service, types of records such as lab results, imaging, therapy notes, operative reports, billing records): ___________ **Dates of Service Covered** (leave blank for entire medical history): From: ___________ To: ___________ --- ## Section 3 — Who Is Authorized to Make This Disclosure **Name or description of the person(s) or organization(s) authorized to make the disclosure:** ___________, ___________, ___________ --- ## Section 4 — Recipient of Information