Client Authorization for Use and
Disclosure of Protected Health Information
By signing, I
authorize Richard I Jontry, Ph.D., to use and/or disclose certain protected
health information (PHI) about me to _________________________.
This
authorization permits Richard I
Jontry, Ph.D., to use
and/or disclose the following individually identifiable health information
about me (specifically describe the information to be used or disclosed, such
as date(s) of services, type of services, level of detail to be released,
origin of information, etc.):
The
information will be used or disclosed for the following purpose:
(If disclosure is requested by the
client, purpose may be listed as "at the request of the individual.")
The purpose(s)
is/are provided so that I can make an informed decision whether to allow
release of the information. This authorization will expire on [enter date or
defined event].
The Practice
will ___ will not ___ receive payment or other remuneration from a third party
in exchange for using or disclosing the PHI.
I do not have to sign this authorization in order to receive
treatment from Richard I Jontry, Ph.D.,.
In fact, I have the right to refuse
to sign this authorization. When my information is used or disclosed pursuant
to this authorization, it may be subject to redisclosure by the recipient and
may no longer be protected by the federal HIPAA Privacy Rule. I have the right
to revoke this authorization in writing except to the extent that the practice
has acted in reliance upon this authorization. My written revocation must be
submitted to:
Signed by:
______________________________ _______________________
Signature of Client or Legal Guardian Relationship to Client
_______________________________ ______________________
Print
ClientÕs Name Date
_______________________________
Print
Name of Client or Legal Guardian, if applicable
Client/guardian
must be provided with a signed copy of this authorization form.
Please also read
Please also read the Notice of Privacy Practices
and sign