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)

    Today's Date (required)

    Your Full Name (required)

    Date of Birth (required)

    Your Email (required)

    Patients City & State (required)

    I authorize Providence Care to obtain my medical information from and release my medical information to: (required)
    my health care providers, including home care agencies, hospitals, nursing homes, and physicians, mental health care providers, Psychiatrist, therapists, social workers/counselors, resources that we work with to obtain community resources or benefits and to my insurers and/or allow review by reimbursement sources who may be involved in paying for Hospice or Palliative services.

    Please list any family members that may not receive information:

    This authorization for release of information covers the period of healthcare from:
    all past, present, and future periods of care.Other
    (If other, please provide dates)

    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)

    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 following (date or event), at which time this authorization expires: (required)
    Continues while under the Care and Services of Providence Care or Providence House CallsContinues until notification in writing by Patient/Representative to Providence Care or Providence House Calls

    By signing below: (required)
    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.

    Patient or Representative Signature (required)

    Relationship to Patient (if Patient cannot Sign):

    Reason patient cannot sign:

    Your Phone Number (required)

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