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HIPAA Medical Information Release Form

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INTRODUCTION: HIPAA Release Form

This document can be used to authorize the release or disclosure of a patient's medical information by
a doctor, medical provider, or facility so that the instructions contained in the patient's Advanced
Healthcare Directive can be carried out.

After this document is printed to paper, the person listed as the patient -- or the patient's
authorized representative -- must sign and date the document where indicated.

Once signed, this document can be given to medical providers, hospitals, doctors, nursing
homes, etc. authorizing the release of the patient's medical information to any other physician,
health or medical care provider, or any other person listed in the patient's Living Will (including
the Attorney-in-Fact).

Disclosure of such information will allow these health care providers and the Attorney-in-Fact
to make informed decisions regarding the Principal's end-of-life care and wishes.

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QUESTIONNAIRE: HIPAA Release Form

1) IDENTITY OF THE PRINCIPAL | Personal information of the Patient, the maker of this document.

Principal's Full Name:

Complete Address:

Phone Number:

Date of Birth:

Last Four Digits, SSN:

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2) IDENTITY OF THE DOCTOR OR FACILITY | The entity requesting this release for records.
Medical Office or Facility:

Patient Account Number:

3) EFFECTIVE AUTHORIZATION DATES | The time period in which the release of medical records is permitted.

Date HIPAA Authorization is Granted:

Date HIPAA Authorization is Revoked:

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 AUTHORIZATION FOR RELEASE OF
HEALTH INFORMATION PURSUANT TO HIPAA

1. Authorization. This form is being provided voluntarily to

thereby authorizing them to disclose the protected health and medical information

of the person/patient listed below:

Patient Name:

Address:

Phone Number:

Date of Birth:

Last 4 Digits of Social Security:

Account or ID Number:

The Patient has prepared and executed an Advanced Healthcare Directive (which
includes a Living Will along with a Power of Attorney for Health Care) and desires that
his/her requests set forth therein be carried out. If any of the Patient's protected health
information need be disclosed to any physician, health or medical care provider, or any
other person listed in the Advanced Healthcare Directive (including the Attorney-in-
Fact) that the Patient has authorized to make health care decisions for him/her, the
Patient hereby authorizes such disclosure with this form.

Further, the Patient's physicians, medical and/or health care providers, along with the
Patient's Attorney-in-Fact listed in the Advanced Healthcare Directive, are authorized to
further release protected health and personal patient information to any other

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 physicians, medical and/or health care providers, as well as those persons listed above,
who, in their professional judgment, would work to further the directives set forth in the
Patient's Advanced Healthcare Directive.

2. Effective Period. This authorization for release of information covers the period of
healthcare from all past, present, and future periods.

3. Extent of Authorization. The Patient authorizes the release of his/her complete

health record, including records relating to mental healthcare, HIV-related information
and the treatment of alcohol or drug abuse.

4. Use of Information. This medical information may be used by the person the
Patient has authorized to receive this information for medical treatment or consultation,
billing or claims payment, or other purposes as the Patient may direct, or as may be set
forth and described in any written instrument and/or the Patient's Living Will.

5. Effective Term. This authorization shall be in force and effect for the following
period: starting date ; ending date .

Outside of these dates, this authorization expires and is void and of no effect.

6. Revocation. The Patient understands that he/she has the right to revoke this
authorization, in writing, at any time. Any revocation must be provided to the facility
where medical records are kept. The Patient understands that a revocation is not
effective to the extent that any person or entity has already acted in reliance on the
authorization or if the authorization was obtained as a condition of obtaining insurance
coverage and the insurer has a legal right to contest a claim. The Patient is aware that if

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 he/she later revokes this authorization, the person(s) herein named may have already
used and/or disclosed protected information on the basis of this authorization.

7. Acknowledgements. The Patient understands that if he/she authorizes protected

health and patient information to be 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.

The Patient understands that he/she has a right to inspect and receive a copies of the
protected health information to be used or disclosed, in accordance with the
requirements of the federal privacy protection regulations found in the Privacy Act and
45 CFR 164.524.d (as may be amended or modified from time to time).

_____________________________________________
Signature of Patient,
or Personal Representative

_____________________________________________
Printed Name of Personal Representative and relationship to patient

Date:

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