Hope & Faith Wellness Clinic - HIPAA Authorization Form
This form is for use when such authorization is required and complies with the Health Insurance
Portability and Accountability Act of 1996 (HIPAA) Privacy Standards.
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Email *
My Authorization
I authorize the following using / disclosing party:
Name / Organization: *
Address: *
Phone *
Fax *
To use or disclose the following health information: *
Required
Purpose
The purpose of the disclosure authorized herein is (check one):
Purpose: *
Required
Duration
I understand that my alcohol and/or drug treatment records are protected under the federal regulations governing Confidentiality
of Alcohol and Drug Abuse Patient Records, 42 CFR, Part 2, and the Health Insurance Portability and Accountability Act of
1996 (HIPAA), 45 CRF, Parts 160 and 164, and cannot be disclosed without my written consent unless otherwise provided for in
the regulations. I also understand that I may revoke this consent in writing at any time except to the extent that action has been
taken in reliance on it, and that in any event this consent expires automatically as follows:
date *
MM
/
DD
/
YYYY
Full Name: *
Age: *
I have read and agreed to the above written *
Required
Submit
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