HIPPA AUTHORIZATION

Ohio HIPAA Privacy Authorization Form**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)

1.
Authorization


I 
authorize BodyGarage Dayton 
to
 use
 and 
disclose 
the 
protected 
health 
information 
described 
below
 to
:

ENTER NAMES BELOW

2.
Effective
Period

This
 authorization 
for 
release
 of 
information 
covers 
the 
period 
of 
healthcare
 from:


a.  January 1st, 2018 to January 1st 2025.

OR

b. all past, present, and future periods.

3.
 Extent
 of 
Authorization


a.
 
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).



**OR**

b.
 
I 
authorize
 the 
release
 of
 my 
complete 
health 
record 
with 
the 
exception


o 
the 
following 
information:

 


□
Mental
health
records





□
Communicable 
diseases
 (including 
HIV 
and
 AIDS)


 


□
Alcohol / drug 
abuse 
treatment

 


4.
This 
medica l
information 
may 
be 
used 
by 
the 
person
I
 authorize
 to 
receive
 this 
information 
for
m medical 
treatment 
or 
consultation, 
billing
or 
claims 
payment, 
or
 other 
purposes
 as 
I
 may
 direct.



5.
This
 authorization 
shall
 be 
in
force 
and
 effect
 until
 December 31st 2025
,
at
 which 
time 
this 
authorization 
expires.


6.
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.



7.
I
understand
that
my
treatment,
payment,
enrollment,
or
eligibility
for
 benefits
will
not
be
conditioned
on
whether
I
sign
this
authorization.



8.
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.


Signature of patient or personal representative
Printed name of patient or personal representative and his or her relationship to patient Date

 
*
Name *
Name
Date *
Date
Please enter the names of the individuals whom have permission to request and receive your medical records from BodyGarage Dayton: