Form – Medical Release HIPAA Privacy Authorization Form **Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)**Name of the Signatory(Required)I, hereby acknowledge that I have read and understand the policies of Blue Sky Health and Wellness. Phone(Required)Email(Required) I authorize Dr Jennifer Sims, D.C. to speak and disclose the protected health information described below to:*(Required)Enter the individual seeking the information here:Effective Period: This authorization for release of information covers the period of heathcare from:*(Required)Please enter effective dates from/to or enter ALL for past, present and future periods.A. Extent of Authorization: I authorize the release of my complete health record (including records relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse).*(Required)Please type YES to authorizeB. Extent of Authorization: I authorize the release of my complete health record with the exception of the following information:*(Required) Mental health records Communicable diseases (including HIV and AIDS) Alcohol/drug abuse treatment Other (please specify in comment box below) Comment BoxNotes to the DoctorAcknowledgements: This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct. This authorization shall be in force and effect until the effective dates listed in this form at which time this authorization expires. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.*(Required)PLEASE SIGN HERE FOR YOUR E-SIGNATURE.Please type full name of patient and/or guardian.(Required)Today's Date(Required) MM slash DD slash YYYY Please do not submit any Protected Health Information (PHI).CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Please do not submit any Protected Health Information (PHI).
