HIPAA Authorization

YOUR COMPANY NAME

Authorization for Use and Disclosure of Protected Health Information

Note: It is office policy of Fictitious Dallas Medical Center not to release confidential medical information regarding your treatment to family members or friends except for:

1. Parent/legal guardian of minor
2. Other person authorized by patient (listed below)
3. Emergency situations
4. Other as permitted by Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Patient Name*

First NameMiddle NameLast Name

Patient DOB*

Date

I DO NOT want my medical information shared with anyone.

I authorize Fictitious Dallas Medical Center to disclose my medical information to:

	Persons Name	Relationship To You
Contact 1
Contact 2
Contact 3

This form provides authorization to Fictitious Dallas Medical Center to use or disclose certain contents of your personal health information to those listed above.

I have received and read a copy of the Notice of Privacy Practices for Fictitious Dallas Medical Center. I hereby authorize the use or disclosure of my health information as described. (If you need another copy please request one at the front desk.)

Date of Signature*

Date

Digital Signature Authorization*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Signature of patient or personal representative*

ClientID