EXAMPLE Authorization for Use and Disclosure of My Protected Health Information

I authorize the use and disclosure of health information about me as described below.

  1. Person(s) or class of persons or entities authorized to use and disclose the information: (name of healthcare provider(s) or health plan(s) you are asking to release your information a/k/a the Disclosing Party)
  2. Person(s) or class of persons or entities authorized to receive the information: Healthper, Inc.
  3. Description of information that may be used and disclosed: (Can be specific, e.g., cholesterol test results. Can be more general, e.g., all health information I request you to submit to Healthper from time to time while this Authorization is in effect. )
  4. I understand that if the person or entity that receives the information is not a health care provider, clearinghouse, or health plan or otherwise covered by federal and state privacy laws (including HIPAA), the information described above may be redisclosed and no longer protected by these regulations.
  5. I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment or health plan payment. I may inspect or copy any information used and disclosed under this authorization.
  6. I understand that I may revoke this authorization in writing at any time by notifying the Disclosing Party in writing, except to the extent that action has been taken in reliance on this authorization. This authorization expires upon the earlier of my revocation or my disenrollment from Healthper.

Signature of Patient or Authorized Representative


Patient’s Name

Name of Personal Representative (if applicable)

Relationship to Patient

A copy of this signed form will be provided to the patient.