EmailMe Form - HIPAA Authorization Form

Patient Name *

Date of Birth *

I hereby authorize the following to disclose my medical record

Name or Organization *

Email *

Effective on: *

MM / DD / YYYY

Expires on: *

MM / DD / YYYY

To use or disclose the following health records: *

All of my health information

My health information relating to the following treatment or condition:

Please specify:

This information may be disclosed by the above party to the following recipients:

Name or Organization *

Email *

The purpose of this authorization is: *

Upon my request

Others (Please specify):_________________________________________________________

Acknowledgment of my rights

I understand this authorization may be revoked at any time except where use or disclosure has already taken place based on my original authorization. If the authorization was to procure insurance, I might not be able to revoke it, and if I do, it has to be in writing and sent to the appropriate disclosing party.

I understand that after original approval, uses and disclosures I have already authorized cannot be undone.

I understand that the recipient may redisclose information used or disclosed with my permission and that the HIPAA Privacy Standards no longer apply.

A copy of this authorization will be provided to me once I sign it. This is a valid version of the original.

Signature of Patient (or Authorized Representative): *

Clear