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Georgia Department
of Human Services
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Name of Individual/Consumer/Patient/Applicant
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Date
of Birth
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IF AVAILABLE:
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ID Number Used by
Requesting Agency
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ID
Number Used by
Releasing
Agency
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AUTHORIZATION FOR
RELEASE OF INFORMATION
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I
hereby request and authorize:
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(Name of Person or Agency
Requesting Information)
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(Address)
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to
obtain from:
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(Name of Person or Agency
Holding the Information)
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(Address)
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the
following type(s) of information from my records (and any specific portion
thereof):
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for
the purpose of:
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I understand
that the federal Privacy Rule
("HIPAA") does not protect the privacy of information if
re-disclosed, and therefore request that all information obtained from this
person or agency be held strictly confidential and not be further released by
the recipient. I further understand that my eligibility for benefits,
treatment or payment is not conditioned upon my provision of this
authorization. I intend this document to be a valid authorization conforming
to all requirements of the Privacy Rule and
understand that my authorization will remain in effect for: (PLEASE
CHECK ONE)
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ninety (90) days unless I
specify an earlier expiration date here:
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one (1) year.
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(Date)
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the period necessary to complete all transactions on matters related
to services provided to me.
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I understand that unless
otherwise limited by state or federal regulation, and except to the extent
that action has been taken based upon it, I may withdraw this authorization
at any time.
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(Date)
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(Signature
of Individual/Consumer/Patient/Applicant)
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(Signature of Witness) (Title or Relationship
to Individual)
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(Signature
of Parent or other legally Authorized (Date)
Representative,
where applicable)
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USE THIS SPACE ONLY IF
AUTHORIZATION IS WITHDRAWN
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(Date
this authorization is revoked by Individual)
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(Signature
of Individual or legally authorized Representative)
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