HIPAA Privacy Authorization Form

Please complete this HIPAA Privacy Authorization Form to grant permission for the release or sharing of your protected health information.

I First Name Last Name make this Authorization to Release Medical Information ("Authorization") to designate the individuals authorized to receive my Medical Information and to designate the individuals authorized to receive my Medical Information and to authorize my Health Care Providers to release my Medical Information to those designated individuals. I authorize my Health Care Providers to disclose and release my Medical Information to any or all of my Personal Representatives:

Primary Health Care Representative; First Name Last Name

Backup Health Care representative; First Name Last Name

Any representative named under my health care directive or other medical or health care power of attorney. It is my intention to provide the Personal Representatives named above broad rights to access and receive my Medical Information. Despite the provisions of HIPAA, I desire my Personal Representatives have access to my Medical Information, at the request of my Personal Representative. This Authorization constitutes a full authorization to disclose any individually Identifiable Health Information to the Personal Representatives named in this Authorization.

I intend this Authorization to be broad and any questions or ambiguities regarding the provisions of this Authorization shall be resolved in favor of allowing the disclosure and release of my Medical Information to my Personal Representatives. This Authorization shall terminate upon my written revocation received by my Health Care provider or 24 months after my death, whichever occurs first.

I declare that I execute it as my free and voluntary act for the purposes expressed therein records.

Name:

Date:

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