Please complete all sections of this HIPAA release form. If any sections are left blank, this form will be invalid and it will not be possible for your health information to be shared as requested.
I,_____________________________________________, give my permission for
______________________________________________ to share the information listed in Section II of this document with the organization I have specified in Section IV of this document.
Section II – Health Information
I would like to give the above healthcare organization permission to:
□ Disclose my complete health record including, but not limited to, diagnoses, lab test results, treatment, and billing records for all conditions.
□ Disclose my complete health record except for the following information
□ Mental health records
□ Communicable diseases including, but not limited to, HIV and AIDS
□ Alcohol/drug abuse treatment records
□ Other (Specify) _________________________________________________________________
Form of Disclosure:
□ Electronic copy or access via a web-based portal
□ Hard copy
Section III – Reason for Disclosure
Please detail the reasons why information is being shared. If you are initiating the request do not wish to list the reasons for sharing, write ‘at my request’.
Section IV – Who Can Receive My Health Information
I give authorization for the health information detailed in section II of this document to be shared with:
Newpoint Partnership Inc
809 Monck St.
Brunswick, GA 31520
I understand that the organization listed above may not be covered by state/federal rules governing privacy and security of data and may be permitted to further share the information that is provided to them.
Section V – Duration of Authorization
This authorization to share my health information is valid for 90 days from the signing of this authorization.
I understand that I am permitted to revoke this authorization to share my health data at any time and can do so by submitting a request in writing to:
I understand that:
In the event that my information has already been shared by the time my authorization is revoked, it may be too late to cancel permission to share my health data.
I do not need to give any further permission for the information detailed in Section II to be shared with the organization listed in Section IV.
The failure to sign/submit this authorization or the cancellation of this authorization will not prevent me from receiving any treatment or benefits I am entitled to receive, provided this information is not required to determine if I am eligible to receive those treatments or benefits or to pay for the services I receive.
Section VI – Signature
Signature: ____________________________________________ Date: __________________
Print your name: _______________________________________________________________
If this form is being completed by a person with legal authority to act an individual’s behalf, such as a parent or legal guardian of a minor or health care agent, please complete the following information:
Name of person completing this form: ___________________________________________
Signature of person completing this form: ___________________________________________
Describe below how this person has legal authority to sign this form: