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 (HIPAA) privacy rule.

 

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:             _________________________________________________________________________

 

Information may be shared by phone, in writing, via computer file, or by email unless otherwise directed below.

Other directions: ________________________________________________________________________

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

                                                         _____ Other (specify):  _______________________________________________

 

My signature indicates I understand and agree that:

• only information that is needed to fulfill the purpose(s) listed above will be released.
• this authorization will remain in effect until and unless JIRA is otherwise notified in writing.
• I can withdraw or take back my permission at any time, by notifying JIRA in writing.
• if I withdraw or take back my permission, information already shared cannot be recalled.
• I may ask for a copy of this signed form, as well as a copy of any records shared.

In addition, 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              Printed Name                                                             Date    

 

Signature of Witness: ____________________________________________    Date: _________________________

Rev. 01-17-2006