SAMPLE HIPAA AUTHORIZATION FORM - Emmes

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SAMPLE HIPAA AUTHORIZATION form . Disclaimer: This document is provided solely for reference purposes. Covered Entities under HIPAA are advised to refer to their Institution's Privacy Policy for specific requirements for the HIPAA AUTHORIZATION . I, ____________________, give permission to [Name of Institution] to: use the following protected health information, and/or disclose the following protected health information to: ________________________________________ ______________________________. ________________________________________ ______________________________. ________________________________________ ______________________________. [Name(s) of entity to receive information]. Information to be disclosed (check all that apply): Medical Records Treatment Records Diagnostic Records Other: ________________________________________ __________________. ________________________________________ __________________.

Sample HIPAA Authorization Form 02/07/03 Page 2 of 2 _____ Signature of Participant or Personal Representative

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