Employee Health Plan
Authorization for Verbal Release of Protected Health Information
Last Name: First: Middle:
Other Names Used: Date of Birth:
Address: City: State: Zip:
Home Phone: Work Phone:
give my permission to the University’s Health Plan to verbally release
information regarding my protected health information
(date) to (date)
maintained or created
by the Health Plan to the recipient named below.
This Authorization applies to my complete medical record OR my psychotherapy notes OR
only this information:
Name of Person: Name of Person:
Relationship to Member:
Relationship to Member:
I understand that:
I may r
evoke this Authorization at any time, in writing. My revocation will not apply to information already retained, used, or
disclosed in response to this Authorization. Unless revoked, the automatic expiration date will be 12 months from the date of the
s the purpose of this Authorization is to determine payment of a claim or benefits, the provision of treatment or
payment for my care may not be conditioned upon my signing of this Authorization.
Information used or disclosed under this Authorization may be subject to re-disclosure by the recipient and no longer
protected by federal privacy regulations.
THE INFORMATION AUTHORIZED FOR RELEASE MAY INCLUDE INFORMATION WHICH MAY
INDICATE THE PRESENCE OF A COMMUNICABLE DISEASE OR A NONCOMMUNICABLE DISEASE.
The information authorized for verbal release may include protected health information related to mental health. Release
of mental health records or psychotherapy notes may require consent of the treating provider or a court order.
The information authorized for verbal release may include drug/alcohol abuse treatment records. This category of
medical information/records is protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules prohibit
anyone receiving this information or records from making further release unless further release is expressly permitted by
the written authorization of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general
authorization for the release of medical or other information is not sufficient for this purpose. The Federal rules restrict
any use of the information to criminally investigate or prosecute any alcohol or drug abuse Member. As a result, by
signing below I specifically authorize any such records included in my health information to be released.
Signature of Member, Parent, or Legally Authorized Representative
Relationship to Member
May be requested to show proof of representative status.
File in Member Chart HIPAA Document
Rev. 1/2015 © 2015 Retain for a minimum of 6 years