Commonwealth of Pennsylvania, Department of Human Services
Authorization for Use or Disclosure of Personal Information
1. I authorize to use/disclose individual
information as described below from the records of:
Name:
Date of Birth: Telephone:
Address:
ID number(s) (identify each type of number)
2. Reason for disclosure:
(Describe each specific purpose - if disclosure is at individual’s request and information to be disclosed
does not include drug and alcohol treatment information, may state, “At the request of the individual”)
3. I understand that:
a. this authorization may be revoked at any time by writing to the individual/organization identified in section 1
except to the extent that information has already been disclosed. If information has already been disclosed in
reliance on this authorization, revoking it will only prevent future disclosure.
b. the Department and its health and human services programs will not condition treatment, payment, enrollment
or eligibility on the provision of this authorization.
c. information (except drug and alcohol information) disclosed pursuant to this authorization may be subject to
redisclosure by the individual/organization identified in section A.2 below and is no longer protected by federal
privacy regulations.
d. the Department, its programs, services, employees, officers, and contractors are hereby released from any legal
responsibility or liability for disclosure of the above information to the extent indicated and authorized.
e. I may refuse to sign this authorization.
PART A - General Information
A.1 Information to be disclosed and time period for records requested (Identify specifically the information
to be used/disclosed such as welfare records, lien records, inspection records, etc. If information to
be used or disclosed includes mental health, drug and alcohol, or HIV-related information, please
complete section of this form that relates to that information):
A.2 This information is to be disclosed to:
A.3 This authorization expires as indicated:
Once acted upon
Other (specify date or event)
HS 1815 3/16
(Insert name or title of the individual/organization to whom disclosure is to be made)
