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{{ practice_addr }} · {{ practice_phone }} · [email protected]
HIPAA Authorization
Auth. No. {{ form_no }}
Issued {{ issue_date }}

Authorization to Use or Disclose Protected Health Information

Compliant with the Health Insurance Portability and Accountability Act · 45 CFR §164.508
Confidential — Patient Authorized
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Patient (Individual Authorizing Disclosure)
Full legal name
{{ patient_name }}
Date of birth
{{ patient_dob }}
Member / account #
{{ patient_id }}
Mailing address
{{ patient_addr }}
Phone
{{ patient_phone }}
2
Disclosing Provider & Authorized RecipientI authorize the provider on the left to release my information to the recipient on the right.
AReleases from — my provider
Provider / practice
{{ from_name }}
Address
{{ from_addr }}
Phone / fax
{{ from_phone }}
BDisclosed to — recipient
Recipient / organization
{{ to_name }}
Address
{{ to_addr }}
Phone / fax
{{ to_phone }}
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Information Authorized for Release
For this underwriting review, I authorize disclosure of the relevant records only checked below — not my complete chart or office visit narratives.
Laboratory resultsBlood panels, urinalysis, screenings
Vital signsBlood pressure, height, weight, BMI
Diagnoses & problem listActive and resolved conditions
Medication listCurrent prescriptions and dosages
Office visit / progress notesExcluded for this purpose
Imaging & radiologyOnly if separately requested
Other (specify):{{ records_other }}
Records dated {{ date_from }}through{{ date_to }} or all available dates
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Purpose & Expiration
Purpose of this disclosure
Insurance underwriting / eligibility Continuing care Personal use Legal
Stated reason
{{ purpose }}
This authorization expires
{{ expiration }}
on or before {{ expire_date }}, or upon completion of the underwriting decision, whichever is earlier. If no date is given it expires one year from signing.
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Your Rights — Please Read Before Signing
  1. Right to revoke. You may revoke this authorization at any time by writing to the Privacy Office above. Revocation stops future disclosures but does not apply to any information already released in reliance on it.
  2. Conditioning. Northgate Internal Medicine will not condition your treatment, payment, or enrollment on whether you sign. However, the recipient named above (an insurer) may lawfully condition coverage or eligibility on receiving this information.
  3. Re-disclosure. Once disclosed to the recipient, your information may no longer be protected by HIPAA and could be re-disclosed by the recipient.
  4. Copies. You are entitled to a copy of this signed authorization, and a photocopy or electronic copy is as valid as the original.
I have read and understand this authorization. I am signing it voluntarily and authorize the disclosure of the information I have marked, to the recipient named, for the purpose stated.
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Signature
{{ patient_sign }}
Signature of patient
{{ sign_date }}
Date signed
{{ patient_print }}
Printed name
{{ patient_dob2 }}
Date of birth
Complete only if signed by a personal representative on the patient's behalf (legal guardian, power of attorney, or executor).
{{ rep_sign }}
Signature of personal representative
{{ rep_relation }}
Relationship / legal authority
{{ rep_date }}
Date
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