Limited Use HIPAA Authorization
Patient Name
Date of Birth
Healthcare Provider/Entity Authorized to Disclose Information
Recipient (Who will receive information)
Description of Information to be Disclosed (be specific)
Purpose of Disclosure
Expiration Date or Event
Signature of Patient or Legal Representative
Date
If signed by Legal Representative, describe authority:
Important Information
You may revoke this authorization at any time in writing.
This authorization is not required for treatment, payment, or enrollment.
Information disclosed may no longer be protected by HIPAA once released.