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Hearing Healthcare Professional Authorization

Download: Hearing Healthcare Professional Authorization

By signing this form, I understand that I am giving [ORGANIZATION] authorization to use or disclose the following information:

Specify Information to be Disclosed:

Recipient. My health information described above may be disclosed by [ORGANIZATION] to the following person(s) or class of persons:

Right to Revoke. I understand that I may restrict the individuals or organizations to whom my healthcare information is released. Further, I understand that I may revoke my authorization at any time; however, my revocation must be in writing, mailed to [ORGANIZATION] at the office address listed below, and [ORGANIZATION] must only comply with such revocation to the extent it is consistent with its Notice of Privacy Practices.

Redisclosure. Information that [ORGANIZATION] uses or discloses based on the authorization I am giving may be subject to re-disclosure by the person who receives the information and may no longer be protected by the federal privacy rules.

Refusal. I have the right to refuse to give [ORGANIZATION] this authorization. If I do not give the authorization, it will not affect the treatment I receive or the methods used to obtain reimbursement for my care, except, however, if my treatment at [ORGANIZATION] is for the sole purpose of creating health information for disclosure to the recipient identified in this Authorization, in which case, [ORGANIZATION] may refuse to treat me if I do not sign this Authorization.

Inspect/Copy. I may inspect or copy the information that [ORGANIZATION] may send at any time.

Term. This notice is effective as of the date set forth below and will remain in effect until: [CHECK ONE OF THE FOLLOWING]

____ The following date or event:______________________.
____ [ORGANIZATION] fulfills the request
____ I provide written notice of revocation to [ORGANIZATION]. The revocation will be effective immediately upon [ORGANIZATION’s] receipt of my written notice, except that the revocation will not have any effect on any action taken by [ORGANIZATION] in reliance on this Authorization before it received my written notice of revocation.

Purpose. I authorize [ORGANIZATION] to use or disclose my health information in the manner described above to the recipient for the term for the following specific purpose [“At the request of the patient” is sufficient if the patient is initiating the Authorization]:

Contact. I may contact [ORGANIZATION’s] privacy officer by mail at:_________________

_________________________ or by telephone at _________________________________.

I hereby acknowledge that I have received a copy of this authorization. I have read and understand the terms of this Authorization and I have had an opportunity to ask questions about the use and disclosure of my health information. By my signature below, I hereby knowingly and voluntarily authorize [ORGANIZATION] to use or disclose my health information in the manner described above.

Signature of Patient (or Personal Representative) Effective Date

Print Patient Name Personal Representative’s Authority

Print Name of Personal Representative (if applicable)