HIPAA Policy | Become Health
HIPAA Authorization for Phi Use or Disclosure
Authorization for Use or Disclosure of Information
I hereby authorize the use and/or disclosure of my “Protected Health Information” (as defined in the Health Insurance Portability and Accountability Act of 1996, as amended (“HIPAA”)) as described below. I understand that this authorization is voluntary.
I understand that once the authorized organization or person receives this information, then it may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy laws.
1. Information to Be Used and/or Disclosed and to Whom.
Name of individual whose PHI is the subject of this authorization
Individual’s date of birth
Name or other specific identification of person(s) or organization(s) authorized to use and/or disclose the Protected Health Information: Become Health, LLC
Specific description of PHI to be used and/or disclosed: Referrals and Prior Authorizations as needed to care for the individual's health.
2. Voluntary and Revocable Authorization.
I understand that this authorization is voluntary and I may refuse to sign it. I acknowledge that I have the right to revoke this authorization at any time by contacting the Plan’s HIPAA Privacy Official. I understand that my revocation must be in writing. I also understand that my revocation will be valid except to the extent that the person(s) or organization(s) authorized to make the requested use and/or disclosure have taken action in reliance on the authorization before it is revoked.
For more information on how to revoke this authorization, contact the Plan’s HIPAA Privacy Official at Become Health, Attn: Privacy Officer, 3538 S Highland Dr, Millcreek, UT 84106.
By writing my signature for approval of this document, I acknowledge and affirm the statements in this authorization form and acknowledge that I have the right to request copy of the signed form.