HIPAA Authorization Form

HIPAA Authorization Form Patient Name: [Sarah Elizabeth Johnson] Date of Birth: [23/05/1990] Address: [45 Elm Street, London, SW1A 0AA] Phone Number: [07700 900345] I, Sarah Elizabeth Johnson, hereby authorise [Dr. Emily White]'s practice to use and/or disclose my protected health information as described below. Purpose of Disclosure: [Coordination of care with specialist physician] Information to be Disclosed: [All medical records pertaining to cardiology and recent MRI results, including progress notes, lab results, and imaging reports from 01/01/2023 to present day.] Recipient(s) of Information: [Dr. David Green, Consultant Cardiologist, St. Jude's Hospital, 123 Oak Avenue, London, W1B 4CD] This authorisation is effective immediately and will expire on [01/11/2025], or upon completion of the stated purpose, whichever occurs first. I understand that I may revoke this authorisation at any time by providing written notification to [Dr. Emily White]'s practice, except to the extent that action has already been taken in reliance on this authorisation. I understand that the information disclosed pursuant to this authorisation may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations. I also understand that I may refuse to sign this authorisation and that my treatment, payment, enrolment, or eligibility for benefits will not be conditioned upon my signing this authorisation. I have been provided with a copy of this signed authorisation. Signature of Patient/Legal Representative: [Sarah Johnson] Printed Name of Patient/Legal Representative: [Sarah Elizabeth Johnson] Date: [01/11/2024] Signature of Witness (if applicable): [Michael Davies] Printed Name of Witness: [Michael Davies] Date: [01/11/2024]