HIPPA Authorization – LEIGH W. JEROME, PH.D.

Name *

First

Last

Date / Time

Date

Time

Address

Address Line 1

Address Line 2

City

State

Zip Code

l, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form:

In accordance with the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPPA), I understand that:

This authorization may include disclosure of information related to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except by psychotherapy notes, and CONFIDENTAL HIVE RELATED INFORMATION only if I place my initials on the appropriate line in item 9(A). In the event the health information described below includes any these types of information, and I initial the line of the box in item 9(A), I specifically authorize release of such information to the person(s) indicated in item 8.
lf I am authorizing the release of HlV-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law.
I have the right to revoke this authorization at any time by writing to the health care provided listed below. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization.
I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.
information disclosed under this authorization might be redisclosed by the recipient if I have agreed to participate in a court ordered evaluation with the recipient, and this redisclosure may no longer be protected by federal or state law.
THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THA THE INDIVIDAUL OR AGENCY SPECIFICED IN ITEM 9(B).
Name and address of health provider or entity to release this information:

Health Provider

Health Provider Address

Address Line 1

Address Line 2

City

State

Zip Code

8. Name and address of person(s) or category of person to whom this information will be sent:

Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

9(A) The specific information to be released:

Medical records From:

To:

Entire medical record, including patient histories, office notes, test results, consults, and records Sent to you by other health care providers. Include: (indicate by initialing)
ALCOHOL/DRUG TREATMENT MENTAL HEALTH INFORMATION H|V-RELATED TNFORMATION

9(B) AUTHORTZATTON TO DTSCUSS HEALTH INFORMATION

By initiating here

Clear Signature

I authorize the discussion of my health information with

9. Reason for release of information:

Custody Evaluation Date
Mental Health Treatment
Review of Prior Treatment
Other

10. Date on which this authorization will expire: (If no date is specified, this will expire in 1 year from date of signature)

Signature of patient or representative authorized by law

Clear Signature

Date