ࡱ > > @ = q` ? bjbjqPqP 4* : : % " 8 $ , " : : " \ \ \ 7 7 7 $ h $ 7 7 7 7 7 \ \ 7 X \ \ 7 \ . =S 0 # B 7 7 7 7 7 7 7 e X 7 7 7 7 7 7 7 " " " " " " " " " PATIENT AUTHORIZATION FOR THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION In accordance with the provisions Section 45 CFR 164.508 of the HIPAA Privacy Regulations (the Regulations) I, the undersigned Patient, authorize the Pharmacy named below to disclose the my Protected Health Information (PHI) that is in the Pharmacys possession or control in accordance with the directions contained in this Authorization. I understand that the PHI disclosed pursuant to this Authorization may be re-disclosed by the recipient and no longer protected under the above Section. I further understand that I have the right to revoke this Authorization in writing, substantially in the form attached, but that any actions already taken in reliance on this Authorization will not be reversed and my revocation will not affect such actions. I. Patients Name: Street Address: City, State, Zip Phone: Cell: Date of Birth: SSN: II. Pharmacy Name: Street Address: City, State, Zip: III. The PHI that is to be disclosed is as follows: _____ All prescriptions dispensed to the Patient between these dates: from / / to / / including DME, _____ All billing records related to the above prescriptions; _____ Other PHI (Describe): This PHI is disclosed for the following purposes (Describe): IV. The PHI is to be disclosed to the following who has agreed to pay the Pharmacy the reasonable charges paid or incurred in providing the copies of the Patients PHI: Name: Street Address: City, State, Zip: Phone: Cell: E-Mail: Fax: V. This Authorization shall be in effect for a period of _____________ next following the date of my signature unless sooner revoked in the manner described above. Signature of Patient or Patients Personal Representative / / Date Description of Personal Representatives Authority to Sign for the Patient (Attach documents) REVOCATION OF AUTHORIZATION This Authorization may be revoked by the Patient by completing the following paragraph and delivering it to the Pharmacy named in the attached Authorization in hand or by certified mail return receipt requested, or by a recognized courier service that provides proof of delivery. Please Note that this Revocation must be received by the Pharmacy at least two business days prior to the below expiration date in order any further disclosures. The attached Authorization is hereby revoked effective at midnight on / / Date Signature of patient or designated Personal Representative / / Date: Description of Personal Representatives Authority to Sign for the Patient (Attach Documents) / / DATE RECEIVED AT THE PHARMACY By: Name Title PAGE PAGE 1 Q R \ ] g h i " & ( ) M Y ] ^ c s } ~ ) * C ¾ƾƺºʲ hO hO >*hO hO hO h7o >*hO h#a >* hO >*h#a hf h7o h hx9 hE0 h