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HIPAA Privacy Authorization Form
Authorization for Use or Disclosure of Protected Health Information
(Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)
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Email
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Your email
Authorization Name:
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I authorize Peaceful Pastures Therapy, LLC, to use and disclose the protected health information described below to
Your answer
Authorization Contact:
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Peaceful Pastures Therapy, LLC, can contact the above mentioned individual at the following (telephone number, email address, physical address, etc.)
Your answer
Effective Period
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This authorization for release of information covers the period of healthcare from:
all past, present, and future periods.
Other:
Extent of Authorization
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I authorize the release of my complete health record (including records relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse)
Other:
This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.
This authorization shall be in force and effect until the date listed below, at which time this authorization expires.
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I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.
I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.
By typing my name in the field below I attest to the above. My typed name shall serve as my signature.
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Your answer
By indicating my date of birth below I attest that the name provided above is my own.
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