HIPAA 404P pg 1
Issued 4/14/03
Authorization to Release or Obtain Health Information
(including paper, oral and electronic information)
Name: Request Date:
Mailing Address: Date of Birth:
City/State/Zip: Medicaid ID # or Social Security #:
I authorize:
Name: _____________________________________________________________________________________
Mailing Address: ____________________________________________________________________________
City, State, Zip Code: ________________________________________________________________________
Relationship: _______________________________ Telephone Number:_____________________________
r TO RELEASE Information TO OR r TO OBTAIN Information FROM
(Place an “X” in the box that indicates if the information is being released OR requested.)
Name: _____________________________________________________________________________________
Mailing Address: ____________________________________________________________________________
City, State, Zip Code: ________________________________________________________________________
Relationship: _______________________________ Telephone Number:_____________________________
The Purpose of this Authorization is indicated in the box(es) below. (Place an “X” in the box(es) that apply.)
r Further Medical Care r Personal r Legal Investigation or Action r
Changing Physicians
r Research related treatment r Creating health information for disclosure to a third party.
I authorize the release of the following protected health information
.
(Place an “X”in the box(es) that apply to the information you want released or you want to obtain.)
r Entire Record r Medical History, Examination, Reports r Surgical Reports r Treatment or Tests
r Prescriptions r Immunizations r Hospital Records including Reports r Laboratory Reports
r X-ray Reports r MR/DD Records r
Other: _________________________________________________
In compliance with state and/or federal laws which require special permission to release otherwise
privileged information, please release the following records.
r Alcoholism r Drug Abuse r Mental Health rVocational Rehabilitation r HIV (AIDS)
r Sexually Transmitted Diseases r Genetics r Psychotherapy Notes
r Other___________________________________________________________________________________
This authorization shall expire on ___________________________________ (date or event) and
is needed for the period beginning ________________and ending _________________.
I understand that if I do not specify an expiration date, this authorization will expire six (6) months from the date
on which it was signed. I acknowledge that I have read both pages 1 and 2 of this form.
____________________________________________________________ _____________________________
Signature of Individual or Personal Representative Authorized by Law Date
For Agency Use When Requesting Records
I am authorized to receive this disclosure. Documentation on the above Personal Representative has been obtained.
______________________________________________________ _________________________
Signature and Title of Agency Representative Date
We may need your authorization to use, disclose or obtain your health information for some of our
services.
You do not have to sign this form. If you agree to sign this authorization to release or obtain information,
you will be given a signed copy of the form.
A separate signed authorization form is required for the use and disclosure of health information for:
ü Psychotherapy notes
ü Employment-related determinations by an employer
ü Research purposes unrelated to your treatment
When required by law or policy, we may only obtain, use and disclose your health information if the
required written authorization includes all the required elements of a valid authorization.
An authorization is voluntary. You will not be required to sign an authorization as a condition of
receiving treatment services or payment for health care services. If your authorization is required by law
or policy, we will use and disclose your health information as you have authorized on the signed
authorization form.
You may be required to sign an authorization before receiving research-related treatment.
You may be required to sign an authorization form for the purpose of creating protected health
information for disclosure to a third party. Example: In a juvenile court proceeding where a parent is
required to obtain a psychological evaluation on their minor child by DHH, the parent may be required to
sign an authorization to release the evaluation report (but not the psychotherapy notes) to DHH.
You may cancel an authorization in writing at any time. We can not take back any uses or disclosures
already made before an authorization was cancelled.
Information used or disclosed by this authorization may be re-disclosed by the recipient and will no longer
be protected by our privacy policies.
Important Information about Authorization
HIPAA 404P pg 2
