HIPAA PRIVACY AUTHORIZATION FORM
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1 535 Independence Parkway, Suite 400 Chesapeake, VA Phone: or Fax: HIPAA PRIVACY AUTHORIZATION FORM **Authorization for Use or Disclosure of Protected Health Information Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164** *** FULFILLMENT STAFF *** PLACE HIPAA FORM RX LABEL HERE FOR PROPRIUM USE ONLY Date Received Back: Scanned In By: V: Authorization I,, authorize PROPRIUM PHARMACY to disclose my protected health information to the following individual: Name Extent of Authorization Relationship to Patient For the purposes of discussing and authorizing pharmaceutical care, billing or claims payment, or other purposes as I may direct. Other purpose: Effective Period This authorization is for the release of medical information and covers the period of healthcare for all past, present and future periods. This authorization shall be in force and effect until revoked in writing or upon the following (date or event ), at which time this authorization will expire. Unless marked as an exception below, I authorize the release of my complete health record to the authorized individual named above. Please place an "x" next to the health record portion you DO NOT authorize us to discuss with this individual: Mental Health Communicable Diseases including HIV/AIDS Treatment of Alcohol or Drug Abuse Other: I understand I have the right to revoke this authorization at any time by providing a written notice of revocation. (Please contact Proprium Pharmacy at (855) or Proprium@sentara.com for further direction.) I understand a revocation is not effective to the extent that any person or entity has already acted in reliance of my authorization, or if my authorization is obtained as a condition of obtaining insurance coverage and the insurer has the legal right to contest a claim. I understand my treatment, payment, enrollment, or elegibility for benefits will not be conditioned on whether or not I sign this authorization. I also understand information used or disclosed pursuant to this authorization may be disclosed to the recipient and may no longer be protected by federal or state law. Printed Name Relationship to Patient if Authorized Agent Signature Date
2 535 Independence Park Chesapeake, VA Phone: o Fax: HIPAA PRIVACY AUTHORIZATION FORM **Authorization for Use or Disclosure of Protected Health Information Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164** *** FULFILLMENT STAFF *** PLACE HIPAA FORM RX LABEL HERE FOR PROPRIU Date Received Back: Scanned In By: V: Authorization I,, authorize PROPRIUM PHARMACY protected health information to the following individual: Name Relationship For the purposes of discussing and authorizing pharmaceutical care, billing or claims payment, or other direct. Other purpose: Effective Period This authorization is for the release of medical information and covers the period of healthcare for all pa future periods. This authorization shall be in force and effect until revoked in writing or upon the follow (date or event ), at which time this authorization will expire. Extent of Authorization Unless marked as an exception below, I authorize the release of my complete health record to the auth named above. Please place an "x" next to the health record portion you DO NOT authorize us to discu individual: Mental Health Communicable Diseases including HIV/AIDS Treatment of Alcohol or Drug Abuse Other: I understand I have the right to revoke this authorization at any time by providing a written notice of rev contact Proprium Pharmacy at (855) or Proprium@sentara.com for further direction.) I unders not effective to the extent that any person or entity has already acted in reliance of my authorization, o is obtained as a condition of obtaining insurance coverage and the insurer has the legal right to contest I understand my treatment, payment, enrollment, or elegibility for benefits will not be conditioned on w this authorization. I also understand information used or disclosed pursuant to this authorization may be disclosed to the r longer be protected by federal or state law.
3 Printed Name Relationship to Patient if Auth Signature Date
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