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Patient HIPAA Form

Limited Patient Authorization for Disclosure of Protected Health Information

Please print all information. Form must be signed and dated each year.




I authorize the entity identified above to disclose or provide protected health information about me to the individual(s) listed below who will be authorized to receive information (list the individual/entity who is to receive your PHI):

* Secure Communication - Note that regular email is not secure, and it is possible for your PHI to be compromised during transmission from our practice. Do not designate email as your preferred method of disclosure if this is of concern to you. Description of information to be disclosed - I authorize the practice to disclose the following protected health.


Purpose of disclosure (please record the purpose of the disclosure or check patient request):
Purpose of disclosure (please record the purpose of the disclosure or check patient request):
*This authorization will expire at the end of the calendar year of your last signature below, unless you specify an earlier termination. You must renew or submit a new authorization after the expiration date to continue the authorization. Please list the date of expiration if earlier than the end of the calendar year

You have the right to terminate this authorization at any time by submitting a written request to our Privacy Manager. Termination of this authorization will be effective upon written notice, except where a disclosure has already been made based on prior authorization. The practice places no condition to sign this authorization on the delivery of healthcare or treatment. We hove no control over the person(s) you have listed to receive your protected health information. Therefore, your protected health information disclosed under this authorization may no longer be protected by the requirements of the Privacy Rule, and will no longer be the responsibility of the practice.


You have the right to receive a copy of signed authorizations upon request.