HIPAA MEDICAL RECORD RELEASE
FOR
N-1
HIPAA Release Authority. In accordance with HIPAA Privacy Rules and Regulations 42 USC 1320d and 45 CFR 160-164, I, N-1 authorize my doctors and all other health care providers and their staffs who are involved in my health care treatment to release information regarding my location, my medical condition, my diagnosis and prognosis and any other information about me, to include individually identifiable health information, that is deemed important by my providers to those persons named on page 2 of this document. This authority is intended by me to allow my heath care providers and their staff to freely converse and communicate, both orally and in writing, with the persons named on page 2.
This document does not grant health care decision-making authority and does not in any way affect, inhibit or otherwise limit the authority granted in any existing healthcare power of attorney that I may have completed.
This document is effective immediately and is durable so that it is not affected by any subsequent incapacity.
The people to whom disclosures can be made are listed on page 2 of this document.
Dated this __________day of __________, 2008.
______________________________
N-1
______________________________
Paralegal, Witness
Sworn and subscribed on this _________ day of ___________, 2008.
______________________________
Attorney Name, Notary Public
HIPAA MEDICAL RELEASE FORM
People that you authorize your doctors and their staff to speak to in the event you are hospitalized.
Relationship Name Address Phone Number
|
Spouse |
|||
|
Son |
|||
|
Daughter |
|||
|
Daughter |
Other Interested Parties
Relationship Name Address Phone Number
______________________ d-t
N-1
