Authorization for Release of Health Information

Which office are you being treated in?*

Toms River
Freehold

Email*

(Required by the Health Insurance Portability and Accountability Act (HIPPA), 45 C.F.R., Parts 160 and 164)

Today's Date*

Patient Name*

First Last

Date of Birth*

1. AUTHORIZATION:

I authorize Pathways Neuropsychology Associates to use and disclose the protected health information described below to:

Physicians:

Attorney:

Other:

2. EFFECTIVE PERIOD:

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

Start Date

to

End Date

**OR**

all past, present & future periods

3. EXTENT OF AUTHORIZATION:

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**

I authorize the release of my complete health record with the EXCEPTION of the following information:

Mental Health Records
Alcohol/drug abuse treatment
Communicable diseases
Demographic information
Other

please specify "Other" if chosen

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

5. This authorization shall be in force and effect until the date specified in Section 2. EFFECTIVE PERIOD, at which time this authorization expires.

6. I understand that I have the right to revoke this authorization, in writing, at any time and this authorization will expire when treatment ends. 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 l sign this authorization.

8. I understand that information used to disclose pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law. I understand that my records are protected under HIPAA State Confidentiality Regulations and cannot be disclosed without my written consent or otherwise provided for in the regulations.

(If patient is a minor (17 & under), both parents or guardians are required to sign this release. If the minor is 14-17 years of age their signature is also required.)

Signature of patient or personal representative*

Date*

Printed Name of patient or personal representative

Relationship to patient

Signature of minor patient 14-17

Date