Authorization to Discuss Medical Information
I hereby authorize you to use or disclose the specific information described below, only for the purposes and
parties also described below.
Description of the specific information to be discussed:
___Appointment Date/Times ___Diagnosis ___X-ray Results ___Medications
___Lab Tests/Results ____ Summary of Medical Record ___Care Plan
___ Other (specify): _________________________________________________________
Indicate Confidential Information: ____Mental Health ___HIV information
____ Alcohol/Drug Information
Patient Name: ____________________________________________________________________
Date of Birth: ____________________________________________________________________
Information to be given to:
Name: __________________________________________________
Relationship:
Address:
Phone:
This authorization shall remain in effect from the date signed below until (please check one):
□ (specify expiration date or event)
□ NO EXPIRATION DATE
I understand that:
I may inspect or copy the protected health information to be used or disclosed.
I may revoke this authorization in writing by contacting your office, attention Administrator.
This authorization is giving Health Center Name the right to discuss my medical information
with the one or more people listed above.
Information used or disclosed pursuant to the authorization may be subject to re-disclosure by
the recipient and no longer be protected by the HIPAA.
I may refuse to sign this authorization and you will not condition treatment or payment on my
providing this authorization (except to the extent that the authorization is for research-related
treatment, in which case you may refuse to provide that research-related treatment).
Signature:
Date:
Relationship to Patient
(If signed by personal representative of Patient):
