I have had the opportunity to read and consider the contents of this authorization. I confirm that the contents are consistent with my direction.
With my initials at categories below, I hereby authorize release of:
________HIV/AIDS Records ________Drug Abuse/History Records _________Mental Health Records
________Genetics Records ________Alcohol Abuse/History Records
_______________________________________________ ___________________________________
(Signature) (Date)
Social Security Number__________-_______-____________ OHP Number_______________________________
Date of Birth (Day)______/(Month)___________________/(Year)_________
Medical or Agency Record Number __________________________________________
If the individual authorizing disclosure is a minor child or a person for whom legal guardianship, conservatorship, or other equivalent limited legal capacity has been established by law, signature of the individual responsible for the protection of the individual's rights under law must appear below.
__________________________________________________ ____________________________________
Signature of person responsible for rights protection of the individual Date
Printed Name of Individual:_______________________________________________________________________
Address of Individual:___________________________________________________________________________
Telephone of Individual:________________________ Social Security Number:______-_____-___________
Individual's Date of Birth:_______________________
____________________________________________________________________________
Relationship or Authority of Person Responsible for Rights Protection of the Individual
_____________________
1Protected health information ("PHI") is health information that is created or received by a health care provider, health plan, or health care clearinghouse which relates to: 1) the past, present or future physical or mental health of an individual; 2) the provision of health care to an individual; or 3) the past present or future payment for the provision of health care to the individual. To be protected, the information must be such that it identifies the individual or provides a reasonable basis to believe that the information can identify the individual. Authority: 45 C.F.R. 164.508., effective April 14, 2003.
2These laws apply to health plans, health care providers, and health care clearinghouses.
OADM Client HIPAA PHI Authorization February 2005