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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)