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Patient Name: Scheduled Date(s): Time: Company: Location: Treatment Authorized by: Signature: Phone: Injury/Accident Date of Injury: Injured Body Part:
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HIPAA stands for Health InsurancePortability and Accountability a HIPPA release and authorization allows anindividual to authorize healthcare providers to release protected healthinformation to third parties under the privacy rules in the Federal HealthInsurance Portability and Accountability Act of 1996 health care providersgenerally are not allowed to disclose protected health information to anyoneother than the patient or the patient's agent without authorization HIPAAprotects an individual's past present or future physical or mental healthcondition the provision of health care to an individual the payment of expensesrelating to the individual's past present or future healthcare anauthorization must specify several things including in some cases thepurpose for which the information may be used or disclosed a description of theprotected health information to be used and disclosed the person authorized tomake the use or disclosure the person to whom the covered entity may make thedisclosure an expiration date or an expiration event that relates to thepatient or the reason for the disclosure of the information the authorizationremains valid until that time or until it is revoked authorization can berevoked at any time a HIPAA release and authorization form only allows the nameagent or agents to access and receive the patient's medical records the agentis not authorized to act on the patient's behalf with respect to medicaldecisions the Privacy Rule does not prohibit doctors nurses laboratory techsor other healthcare providers from the medical records of the patient if theinformation needs to be shared for the health of the patient there is norequirement that a release and authorization form be notarized moreinformation for HIPAA authorization can be found on the US Department of Healthand Human Services website WWH HHS govt