HIPAA Form

Authorization for Use or Disclosure of Information for Purposes Requested by Chiropractor

Note to Doctors:  Please read the following disclaimers before using this form.

(1)  This information is provided for educational purposes.  Neither its author nor the WCA is engaged in the practice of law by preparing or printing this form.  No standard form is a proper substitute for professional legal advice from an attorney licensed to practice in your jurisdiction.

(2)  Some states have privacy laws in additional to the federal HIPAA.  This may require some adaptation of forms that are designed solely for HIPAA compliance.  This is another reason to take any form to a lawyer in your state to have it reviewed before using it in your office.

(3)  Below is merely one example of the kind of Authorization that may be used under HIPAA.  It does not provide for every type of disclosure for which permission may be sought.  For this reason, this form may be modified, with proper legal advice, to suit other purposes.

[Letterhead or Name of your Practice]

Authorization for Use or Disclosure of Information
for Purposes Requested by Chiropractor (3/03)

In this document, “I” and “my” refer to the patient,
and “Chiropractor” refers to [insert name of chiropractic practice].

I hereby authorize Chiropractor to (check those that apply):

_____ use the following protected health information, and/or

_____ disclose the following protected health information to the following entity:

______________________________________________________________________________

Information to be used or disclosed:

Date of service:  ________________________________________________________________

Type of service:  ________________________________________________________________

Level of detail to be released:  _____________________________________________________

Origin of information:  ___________________________________________________________

This protected health information is being used or disclosed for the following purposes:

______________________________________________________________________________

This authorization shall be in force and effect until ____________________________________, at which time this authorization to use or disclose this protected health information expires.

I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to the Privacy Officer of the Chiropractor, at [insert office address of Chiropractor].  I understand that a revocation is not effective to the extent that Chiropractor has relied on the use or disclosure of the protected health information.  I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law.

Chiropractor will not condition my treatment, payment, enrollment in a health plan, or eligibility for benefits (if applicable) on whether I provide authorization for the requested use or disclosure.

I understand that I have the right to inspect or copy the protected health information to be used or disclosed as permitted under federal law (or state law to the extent the state law provides greater access rights) and/or to refuse to sign this authorization.  I understand that the use or disclosure requested under this authorization may result in direct or indirect remuneration to Chiropractor from a third party.  [Delete last sentence if inapplicable.]

______________________________________      ____________________________________

Signature of Patient or Personal Representative               Printed Name of Patient

________________________________    __________________________________________

Date of Signing                                        Description of Personal Representative’s Authority