Ingenuity Insights

Ingenuity Insights 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 (healthcare provider) to use and disclose the protected health information described below to (individual seeking the information).
  2. Effective Period
    • This authorization for release of information covers the period of healthcarefrom: to .
      • **OR**
    • all past, present, and future periods.
  3. Extent of Authorization
    1. 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).
      2. **OR**
    2. I 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 (please specify):
    3. 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.
    4. This authorization shall be in force and effect until (date or event), at which time this authorization expires.
    5. 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.
    6. 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/Representative



Printed name of patient or Representative



Relationship to patient



Date