0920-1331 Release of Information (HIPAA Privacy Authorization Form

Appendix N

Release of Information (HIPAA Privacy Authorization Form)

Form Approved

OMB No. 0920-1331

Exp. Date xx/xx/20xx

Authorization for use or disclosure of protected health information (required by the Health Insurance Portability and Accountability Act, 45 CFR, Parts 160 and 164)

1. I authorize ____________________ (healthcare provider) to disclose the protected health information described here to Kristin Yeoman, MD.

__________________________________________________________________________________________________________________________________________________________________________

2. Effect period ________ to _________ (authorization for release of information covers this period)

3. Use. This medical information may be used to determine eligibility for NIOSH/CDC study.

4. Termination. This authorization shall be in force and effect until _________, at which time this authorization form expires.

5. Revocation rights. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

Patient signature ____________________________

Printed name ___________________________________

Date ________________

CDC estimates the average public reporting burden for this collection of information as 1 minute per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1331).