HIPAA Authorization


Please complete the HIPAA Privacy Authorization and Consent for Medical Records Release.

HIPAA Authorization

**Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act 45 C.F.R. Parts 160 & 164) **

Authorization: I authorize Core Health Psychiatry (healthcare provider) to provide medical information to the person authorized below as well as my health care provider, DSS, and other entities as needed:

Effective Period: This authorization for release of information covers for a year unless an end date is appended by patient. Extent of Authorization: I authorize the release of my complete health records including records related to Mental Healthcare, communicable diseases, HIV or AIDS, and treatment of drug or alcohol abuse). As a patient I can exercise my right to not release the following: Mental Healthcare, Drug and alcohol abuse treatment, and communicable diseases (HIV or AIDS).

1.) 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.

2.) I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.

3.) 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.

Consent for Release of Protected Health Information to Family

I authorize Core Health to release to my insurance company, consulting physician, department of social services, and other agencies on my behalf by mail, fax or secure internet information concerning health care, advice, treatment, or supplies provided to me. This information will be used for treatment, payment and operations. Refer to Privacy Notice.

Consent for Medical Records Release

- All my medical information- Information necessary to schedule appointments for me
- Lab or test results
- Information necessary to provide, call in or pick up prescriptions for me
- Information necessary to help my family member(s) take care of me
- Information necessary to allow my family member(s) to pick up or arrange for medical equipment to be provided for me
- Information necessary to bill for or submit claims for care provided to me or to government or private insurance payors,

Medicare Patients Only

I request the payment of authorized Medicare benefits be made on my behalf to Core Health for any services rendered to me on behalf of my provider. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents, by mail or fax; any information needed to determine these benefits or benefits payable for related services.,

My consent will remain in effect as long as I am a patient or until I notify Core Health in writing of any changes.