PARENTS -- The moment your child turns 18 their medical providers will not talk to you -- you need the following HIPAA Release in order to have access to their medical providers OR ask their medical care provider to provide a form for the 18 yr. old to sign.
If your child is headed to college, you definitely need to have your child sign this document or a similar document to have access to their records in case of an emergency.
(This happened to my child -- she almost died her second year of college -- she was in another city & thankfully I had this form so that I could talk to her medical care providers while she was too ill to speak.)
I encourage every parent to have their adult children execute this information so that they can continue to communicate with their medical providers.
Be aware that the 18 year old can revoke this permission at any time.
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HIPAA
RELEASE
I, __________________________, intend
for any agent named in this release to be treated as I would be treated with
respect to my rights regarding the use and disclosure of my individually
identifiable health information and 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 C.F.R. 160-164.
I authorize the disclosure of any
information governed by HIPAA to be provided to the following: __________________________________.
(include full legal name, relationship, address, phone number & email address)
Accordingly, I hereby authorize any
physician, health-care professional, dentist, health plan, hospital, clinic,
laboratory, pharmacy 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 any agent who is named herein and who is currently serving as such,
without restriction, all of my individually identifiable health information and
medical records regarding any past, present or future medical or mental health
condition, including all information relating to the diagnosis and treatment of
HIV/AIDS, sexually transmitted diseases, mental illness, and drug or alcohol
abuse.
This authority given to any named
agent shall supersede any prior agreement that I may have made with my
health-care providers to restrict access to or disclosure of my individually
identifiable health information.
The
individually identifiable health information and other medical records given,
disclosed, or released to any named agent may be subject to redisclosure by a
named agent and may no longer be protected by HIPAA.
The authority given to any named agent herein
has no expiration date and shall expire only in the event that I revoke this
HIPAA Release in writing and deliver it to my health-care provider.
There are no exceptions to my right to revoke
this HIPAA Release.
PRINTED NAME & THEN SIGNATURE
DATE OF BIRTH:
LOCATION OF BIRTH:
LAST 4 DIGITS OF SS#:
ADDRESS
PHONE NUMBER
EMAIL ADDRESS
SUBSCRIBED AND SWORN TO BEFORE ME
by the said _____________________, Principal, this day of
, 20___.
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