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HIPAA AUTHORIZATION FOR USE OR DISCLOSURE OF
HEALTH INFORMATION
Date: _______________, ____
I. THE PATIENT. 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.
Patient’s Name: ________________________
Date of Birth: _______________, ____
Social Security Number: _____-____-_____
II. AUTHORIZATION. I authorize ________________________ (“Authorized Party”) to use
or disclose the following: (check one)
☐ - All of my medical-related information.
☐ - My medical information ONLY related to: ________________________.
☐ - My medical-related information from _______________, ____ to
_______________, ____.
☐ - Other: ________________________________________________.
Hereinafter known as the “Medical Records.”
III. DISCLOSURE. The Authorized Party has my authorization to disclose Medical Records
to: (check one)
☐ - Any party that is approved by the Authorized Party.
☐ - ONLY the following party:
Name: ________________________
Address: ________________________________________________
Phone: (____) ____-______ Fax: (____) ____-______
E-Mail: ________________________
IV. PURPOSE. The reason for this authorization is: (check one)
☐ - General Purpose. At my request (general).
☐ - To Receive Payment. To allow the Authorized Party to communicate with
me for marketing purposes when they receive payment from a third party.
☐ - Other: ________________________________________________.
225 Wilmington West Chester Pike Glenn Mills,
PA 19342
PSHAdmin - 015
Expiration Date 1/1/2025