8. Form: HIPAA AUTHORIZATION
Pursuant to 45 CFR § 164.508 (b) and (c), I, ______________________,
hereby authorize the person or persons named to review, copy, discuss,
release and generally to have access to my personally identifiable
health and related information as indicated below:
1. Person(s) authorized:
Name: ________________________________
Address: ______________________________
______________________________
Name: ________________________________
Address: _______________________________
_______________________________
2. Information to be released:
The person(s) named
above is/are authorized to access,
view and copy, and covered entities are authorized to provide them
access, to: Any and all health , health care and related information
of all kinds and in any form.
3. Purpose:
The described information shall be released at the request of those
named above, as may be needed to assist in my treatment and care,
to make health care decisions, and for any other reason at the discretion
of the said designee(s).
4. Expiration, right to revoke:
This authority shall continue until my death unless earlier revoked
by me, and I understand that I may revoke it at any time.
5. Non-liability of provider:
Once the requested
information is disclosed to the person(s)
I have designated, the provider shall have no liability for any
redisclosure of the Information by the recipient.
I am signing this document on the _______ day of ________________,
200___.
I have read it, I understand it and I am signing it voluntarily,
with the intention that the person(s) named shall have the same
access to my personally identifiable health care and related information
as I have myself.
Signature of Grantor: ____________________________
Name typed or printed: ___________________________
Witness: ________________________
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