Authorization for [insert physician or practice name] to Use or Disclose My Health Information
 Patient name: ___________________________________________________________________________ 
 Date of birth:______________________________		SSN: ______________________________

I.  My Authorization
You, [insert physician or practice name], may use or disclose the following health care information: 
 All my health information maintained by you
 My health information relating to the following treatment or condition: _________________________________
 My health information for the date(s):____________________________________________________________
 Other:_____________________________________________________________________________________
You may disclose this health information to:
Name (or title) and organization__________________________________________________________________
Address: _________________________________City ________________________State _________Zip_______
Reason(s) for this authorization (check all that apply):                          

 at my request 	 check here only when [insert physician or practice name] will get something of value for providing health  information for marketing purposes	
 other (specify)____________________________________
__________________________________________________________________________________________________		

This authorization ends:      	 on (date) __________________ 
 when the following event occurs _____________________________________

II.  My Rights
I understand I do not have to sign this authorization in order to receive treatment.  However, I may be required to sign this authorization form:
•	To take part in a research study; or
•	To receive health care when the purpose is to create health information for a third party.
I may revoke this authorization at any time, in writing, sent to [insert physician or practice name] at the address provided below.   If I do, it will not affect any actions already taken by [insert physician or practice name] based upon this authorization; uses and disclosures already made cannot be taken back.  I may not be able to revoke this authorization if its purpose was to obtain insurance. 
•	[insert physician or practice address] 
Once the office discloses health information, the person or organization that receives it may re-disclose it.  Privacy laws    may no longer protect it.
I will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original.
___________________________________________	__________________	____________________
Patient or legally authorized individual signature			Date				Time
Patient is unable to sign because of: _______________________________________________
		Age of minor or reason for patient’s inability to sign		
___________________________________________	______________________________________________
Printed name if signed on behalf of the patient  			Relationship & Authority (parent, legal guardian, personal representative, etc.)
III.  Additional Consent for Certain Conditions

This medical record may contain information about physical or sexual abuse, alcoholism, drug abuse, sexually transmitted diseases, abortion, or mental health treatment.  Separate consent must be given before this information can be released.
•	I consent to have the above information released.
•	I do not consent to have the above information released.  
___________________________________________	__________________	____________________
Patient or legally authorized individual signature			Date				Time

IV.  Additional Consent for HIV/AIDS

This medical record may contain information concerning HIV testing and/or AIDS diagnosis or treatment.  Separate consent must be given to have this information released.
•	I consent to have the above information released.
•	I do not consent to have the above information released.
___________________________________________	__________________	____________________
Patient or legally authorized individual signature			Date				Time