Individual: SSN:DOB:

I understand that this authorization is voluntary and I may refuse to sign this authorization without affecting my health care or the payment for my health care. I further understand that I have the right to request a copy of this form after I sign it as well as inspect or copy any information to be used and/or disclosed under this authorization (if allowed by state and federal law. See 45 CFR §164.524).

I hereby authorize the designated staff at ______to use/disclose my protected health information as described below to:

(name and address of recipient)______

______

Type of Information to Be Disclosed:

Entire Medical Record
Progress Notes
Billing Statements
Laboratory Reports
Medication Notes
Nursing Notes
Discharge Summary / History and Physical Exam
Emergency and Urgent Care Records
Diagnostic Imaging Reports
Training/Habilitation Records
Psychiatry/Psychology Records
Audio/Visual/Dental Records
Case Management Notes / Plans of Care/Treatment Objectives
Radiology Reports
Other ______
______

I also authorize the disclosure/use/receipt of my health information regarding:

HIV/AIDS infection / Drug/Alcohol abuse

This disclosure is for the following purpose(s):

To coordinate my discharge planning/placement at my request

To assist in my educational placement to assist in additional funding

To discuss with my family the care and treatment I receive

Other:

Note: If you are authorizing disclosure of information, then, except for information related to alcohol or drug abuse treatment, the potential exists for the information described in this authorization to be re-disclosed by the recipient. If the information is re-disclosed, then it is no longer protected by privacy laws.

Note: If you are signing as a parent/guardian/managing conservator of a minor or as a guardian of the person of an adult, the information disclosed/used/received may contain references about you and your family.

You have the right to revoke this authorization. To revoke this authorization, you must deliver a written statement, signed by you, to D&S Residential Services, LP, the Company where you gave your authorization, which provides the date and purpose of this authorization and your intent to revoke it. Your revocation will be effective the date it is received by D&S Residential Services, LP except to the extent that D&S Residential Services, LP has already relied upon your authorization to use or disclose your health information as described in the Notice of Privacy Practices.

Expiration:

This authorization will expire 180 days from the date of signing, unless it is revoked earlier.

Individual’s Name: ______
______
Signature of Individual or Legal Representative / ______
Date
______
Printed Name of Individual’s Representative (if applicable) / Relationship to Individual (if applicable)
Parent or guardian of unemancipated minor
Court appointed guardian
Executor or administrator of decedent's estate
Power of Attorney
______
Signature of Witness / ______
Date

Authorization for Use and Disclosure of Protected Health Information

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