HIPAA Authorization

HIPAA Authorization

Provided by: Wellness Grove
Client Legal Name*

First NameMiddle NameLast Name
Client Preferred Name
Client Date of Birth*

MonthDayYear
Last 4 of SS# for Client*
Client Age
Current Date

MonthDayYear
If the client is under 18 years old you will be required to describe your relationship to the client at the end of the HIPAA authorization form.
Email Address*

Confirmation Emailexample@example.com
Name of Individual Completing Form (if not the client)

First NameLast Name

Protected Health Information (PHI)

I understand that my Protected Health Information (PHI) is protected under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I hereby authorize the release of my Protected Health Information (PHI) as described below, pursuant to the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.
Recipients

I hereby authorize and provide consent for communication of my Protected Health Information (PHI) be granted between Wellness Grove and the Recipients listed below. I understand that this HIPAA Authorization form does not provide authorization for Wellness Grove to release medical records.
Recipient List*
Revocation

I understand that I have the right to revoke this authorization in writing or verbally at any time, except to the extent that action has already been taken based on this authorization.
Expiration

Unless sooner revoked, this authorization expires in 365 days.

Acknowledge & Sign
By signing this form electronically and clicking on "Sign & Submit", you are certifying your agreement to the HIPAA authorization form. Please note that an e-signature is the electronic equivalent of a hand-written (pen-and-paper) signature.*

Clear
Input Legal Name*
Client or Parent/Guardian/Legal Representative
Date*

MonthDayYear
If Parent/Guardian/Legal Representative, please describe your relationship to the client
Should be Empty:

Protected Health Information (PHI)