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Authorization for Release of Protected Health Information

This form authorizes Jones Institute for Rehabilitative Audiology, LLC (JIRA) to share personal health/medical information that is protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Information about:

Patient Name:                                                                                                                                     

Date of Birth:                                                                                                                                      

Address:                                                                                                                                             

            Phone:                                                                         E-mail:                                                            

May be shared between JIRA and the following:

Name:                                                                                                                                                 

Agency:                                                                                                                                              

Address:                                                                                                                                             

Phone:                                                                         Fax:                                                                

E-mail:                                                                                                                                                

Specific description of the heath information to be shared (include dates of service, appointment dates, type of service, etc.):                                                                                                                                                                           

Information may be shared using a variety of methods, including, but not limited to, by phone, in writing, by fax, via computer file, or by email unless otherwise directed or restricted below.

_____  No restrictions

_____  Other directions/restrictions:                                                                                                               

The purpose of this release is:             Coordination of care for the named patient.

                                                             Other (specify):                                                                                             

My signature below indicates I understand and agree that:

  • Only information that is specified above and needed to fulfill the purpose(s) listed above will be released.
  • This authorization is voluntary. I may refuse to sign this authorization and the patient's treatment and/or payment obligations will not be affected unless either of the following applies: (a) treatment is related to research and the sharing of information is related to such research; or (b) treatment is solely for the purpose of creating protected health information for disclosure to a third-party.
  • JIRA will not receive financial or in-kind compensation or remuneration in exchange for sharing protected health information unless an applicable legal exception applies.
  • Health information shared may be subject to redisclosure by the recipient of the health information and may no longer be protected by federal or state law.
  • Unless otherwise revoked, this authorization will expire on __________ (date, event, or condition). If I fail to specify a date, event, or condition, this authorization will expire in one (1) year.
  • I may revoke this authorization at any time by notifying JIRA in writing, but, if I do, it will not have any effect on uses or disclosure prior to the receipt of the revocation.
  • I can ask for a copy of this signed form, as well as a copy of any records shared.
  • A photocopy or facsimile of this authorization will be valid and effective, just as the original.

I have the authority to give the permission described above and am doing so voluntarily.

                                                                                                                                                                                   

Patient Signature if 14 or older                                                                        Printed Name                           Date

                                                                                                                                                                                   

Parent/Guardian/Personal Representative (if applicable)                                  Printed Name                           Date

                                                                                   
Relationship of Representative to Patient (if applicable)                                                                                      
Rev. 11-28-2012

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