HIPAA Disclosure of Health Information

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Patient Name:

First Name

Last Name

HIPAA Authorization for Use or Disclosure of Health Information

I give permission to Internal Reflections, LLC, to disclose and release my protected health information described below to:

Name (or title) and organization:

Email Id:

Mobile No:

Address:

Address Line1

Address Line2

Land Mark

City

State

Country

Zip Code

Health Information to be disclosed (Check all that apply):

My complete health record (including but not limited to diagnoses, lab tests, prognosis, treatment, and billing, for all conditions)
My complete health record, as above, with the exception of the following information: (check as appropriate):
Mental health records
Communicable diseases (including HIV and AIDS)
Alcohol/drug abuse treatmen

Form of Disclosure (unless another format is mutually agreed upon between my provider and designee):

An electronic record or access through an online portal
Hard copy

This authorization shall be effective until (check one):

All past, present, and future periods, OR
Date or event

Date or event for authorization:

My Rights

I understand that I have the right to revoke this authorization, in writing, at anytime, except where uses or disclosures have already been made upon my original permission. In order to revoke this authorization.

I understand that it is possible that information used or disclosed with my permission may be re-disclosed by the recipient and is no longer protected by the HIPAA Privacy Standards.

Name of the Individual Giving this Authorization:

First Name

Last Name

Signature of the Individual Giving this Authorization:

Date:

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HIPAA Authorization for Use or Disclosure of Health Information

My Rights