HIPAA Privacy Authorization Form

Patient Form

Patient Name(Required)

Date Of Birth(Required)

Authorization

I authorize Callahan Clinic to use and disclose the protected health information described below to the following individuals names and phone numbers:

List(Required)

Name

Phone Number

Effective Period

This authorization for release of information covers the following period of healthcare(Required)

From ______ to _______

All past, present, and future periods

I understand that I have the right to revoke this authorization, in writing at any time.

Extent of Authorization

I authorize the release of my complete medical record (including records relation to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse) I Authorize the release of my complete heath record with the exception of the following information:(Required)

Mental Health Records

Communicable Diseases (including HIV and AIDS)

Alcohol-drug abuse treatment

Other

Date(Required)

This document is effective for one year unless a date has been specified below

Signature(Required)

Date(Required)

Verification

Patient Form

Accepted Insurances