Model HIPAA Privacy Authorization


 Statement of Intent: It is my understanding that Congress passed a law entitled the Health Insurance Portability and Accountability Act (“HIPAA”) that limits use, disclosure or release of my health information.  I am signing this Authorization because it is crucial that my health care providers readily use, release or disclose my protected medical information to, or as directed by, that person or those persons designated in this Authorization to allow them to discuss with, and obtain advice from, others or to facilitate decisions regarding my health care when I otherwise may not be able to do so without regard to whether my health care provider has certified in writing that I am incompetent for purposes of HIPAA.

 A.        The persons named below in Paragraph B, individually and severally, shall have the power and authority to do all of the following:

 (1)        Request, review, and receive, to the extent I could do so individually, any information, verbal or written, regarding my physical or mental health, including, but not limited to, my individually identifiable health information or other medical records. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. 1320d and 45 CFR 160-164. I hereby authorize any physician, health care professional, dentist, psychiatrist, psychologist, therapist, nurse, health plan, hospital, clinic, laboratory, pharmacy, ambulance service, assisted living facility, residential care facility, nursing home or other covered health care provider, any insurance company, and the Medical Information Bureau, Inc., or other health care clearinghouse that has provided treatment or services to me, or that has paid for or is seeking payment from me for such services, to give, disclose, and release to the persons named herein, without restriction, all of my individually identifiable health information and medical records regarding any past, present, or future medical or mental health condition.

This authority shall supersede any other agreement which I may have made with my health care providers to restrict access to or disclosure of my individually identifiable health information. This authority shall be effective immediately, has no expiration date and shall expire only in the event that I revoke the authority in writing and deliver it to my health care provider;

 (2)        Execute on my behalf any releases or other documents that may be required in order to obtain this information;

 (3)        Consent to the disclosure of this information;

 B.        The persons who shall have the powers hereinabove described in Paragraph A are:


123 Main Street, Anytown, USA

 This Authorization is not affected by, and shall not terminate by reason of, my subsequent disability or incapacity.  This Authorization shall terminate two years following my death or upon written revocation expressly referring to this Authorization and the date it is actually received by the covered entity. 




Law Office of Eileen Guerin Swicker 20 W. Market St. Suite E, Leesburg, VA 20176 Tel: 571-918-0616