The Missouri HIPAA Privacy Authorization Form is a document that allows individuals to authorize the use or disclosure of their protected health information. This form is essential for ensuring that personal health data is shared only with designated individuals or entities, in compliance with the Health Insurance Portability and Accountability Act (HIPAA). For those needing to manage their health information, filling out this form is a crucial step; click the button below to get started.
The Missouri HIPAA form is an essential document designed to protect your health information while allowing for its necessary disclosure. This form authorizes healthcare providers to share your protected health information with designated individuals or entities. It covers a range of health records, including sensitive information related to mental health, communicable diseases, and substance abuse treatment. You can choose to release your complete health record or specify exclusions for certain types of information. This flexibility ensures that you maintain control over your personal data. The authorization remains effective until a specified date or event, and you have the right to revoke it at any time, although this revocation won't affect actions already taken based on your original consent. Importantly, signing this form does not impact your eligibility for treatment or insurance benefits. Understanding the implications of this authorization is crucial, as once your information is shared, it may no longer be protected under HIPAA regulations.
HIPAA Privacy Authorization Form
Authorization for use or disclosure of protected health information. (Required by the Health Insurance Portability and Accountability Act
– 45 CFR Parts 160 and 164)
Return to: Missouri Attorney General’s Office Attn: Jodi Lehman
PO Box 899
Jefferson City, MO 65102
MISSOURI ATTORNEY GENERAL
573-751-3321
CHRIS KOSTER
AGO.MO.GOV
1
I hereby authorize
to use and/or disclose the
NAME OF HEALTH CARE PROVIDER
protected health information described below to
.
NAME OF INDIVIDUAL
2
Authorization for Release of Information. Covering the period of health care from
to
OR
All past, present and future periods:
a
I hereby authorize the release of my complete health record (including records relating to mental health care,
communicable diseases, HIV or AIDS, and treatment of alcohol/drug abuse).
b
I hereby authorize the release of my complete health record with the exception of the following information:
Mental health records
Communicable diseases (including HIV and AIDS)
Alcohol/drug abuse treatment
Other:
3
4
5
6
7
This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.
This authorization shall be in force and effect until
,
at which time this authorization expires.
DATE OR EVENT
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.
I understand that my treatment, payment, enrollment or eligibility for benefits will not be conditioned on whether I sign this authorization.
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
DATE
PRINT NAME OF PATIENT OR PERSONAL REPRESENTATIVE
RELATIONSHIP TO PATIENT
APRIL 2009
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