To have access to and to authorize release of my medical records
and other personal information; This document is meant to be an unlimited,
full and complete Power of Attorney for the release of any and all protected
medical information as defined under the Health Insurance Portability and
Accountability Act of 1996 (HIPAA), as amended and under the rules and
regulations thereunder, and covers all protected information from primary and
secondary providers, health plans, health care clearing houses, emergency
services, financial and administrative transactions, psychotherapy treatment,
and business associates. It is understood that the person to whom this Durable
Power of Attorney is given has my permission to use and disseminate this
information in his or her sole discretion.
RE: (Patient Name) ____________________________
Social Security Number: _______________
- This release authority applies to any information governed by the Health
Insurance Portability and Accountability Act of 1996 (a/k/a HIPAA), 42 USC
132d and 45 CFR 160-164. Specifically, this release authority complies with
the valid authorization requirements of 45 CFR 164.508 (c).
- Pursuant to HIPAA, I authorize and direct any physician, healthcare
professional, dentist, health plan, hospital, clinic, laboratory, pharmacy,
or other covered health care provider, any insurance company, and the Medical
Information Bureau, Inc., or other health care clearinghouse that has provided
treatment or services to me or that has paid for or is seeking payment from me
for such services, to give, disclose, and release,
without restriction, all of my individually identifiable health information and
medical records regarding any past, present, or future medical or mental health
condition, to include all information relating the diagnosis and treatment of
sexually transmitted diseases, mental illness, and drug or alcohol abuse
separately to the following person or persons:
- This authorization specifically applies to all health care providers and
any records that may be requested.
- The purpose of the use and disclosure shall include assistance by my
Authorized Person(s) in monitoring my health care and sharing my health care
status with family and friends for my benefit.
- I understand that, with certain exceptions, I have the right to revoke this
Authorization at any time. If I want to revoke this Authorization, as well as
the exceptions to my right to revoke will be performed in accordance with
applicable federal law and any applicable policy of my health care provider.
- I understand that, I may refuse to sign this Authorization. I also understand
that my healthcare provider cannot deny or refuse to provide treatment, payment,
enrollment in a health plan, or eligibility for benefits if I refuse to sign this
- I understand that, once information is disclosed pursuant to this Authorization,
it is possible that it will no longer be protected by applicable federal medical
privacy law and could be re-disclosed by the person or agency that receives it,
however, I do not authorize such secondary disclosure.
- The authority given to said Authorized Person(s) shall supercede any prior
agreement that I may have made with my health care providers to restrict access to
or disclosure of my individually identifiable health information. The authority
given has no expiration date and shall expire only in the event that I revoke the
authority in writing and deliver it to my health care provider.
I have read and understand the information in this authorization form.
Signature: ____________________ Date: ________________________
Print Name: _____________________
Witness: _____________________ Witness: _____________________