CFMZ01 HIPAA Authorization 1.1

CUMBERLAND FAMILY MEDICINE, LLC

Authorization for Use and Disclosure of Protected Health Information

Note: It is office policy of Cumberland Family Medicine, LLC 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 Cumberland Family Medicine, LLC to disclose my medical information to:

Rows	Person Name	Relationship
Contact 1
Contact 2
Contact 3

ALLOther

This form provides authorization to Cumberland Family Medicine, LLC to use or disclose certain contents of your personal health information to those listed above.

The disclosure of any part of the medical record deemed to be “psychotherapy notes” will require a separate authorization. I understand that if my records contain information about HIV/AIDS status this could be released to only those listed above or for any of the reasons listed above.

I have received and read a copy of the Notice of Privacy Practices for Cumberland Family Medicine LLC. 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.)

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.

Patient Digital Signature*

Name of patient or personal representative and relationship *