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SAMPLE HIPAA AUTHORIZATION FORM - Emmes

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: _____. _____. _____. This protected health information is being used or disclosed for the following purposes: _____. _____.

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

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