- 1). Provide written notification to your medical care provider granting authorized medical staff permission to distribute your personal health information.
- 2). List the full name of each person to whom you wish to grant access to your personal health information. Examples include a spouse, parent, adult child, caretaker or personal representative, such as a person with power of attorney.
- 3). Identify the preferred delivery option, such as disclosure by phone, and state a reason for the authorization such as, "The person assists me with medical needs."
- 4). Waive your federal privacy protection rights and state that you wish to grant authorization until a specified date. Acknowledge that your statements are true and cannot result in the refusal of medical care or benefits for refusal to sign a new HIPPA authorization at the time of a medical service.
- 5). Provide your medical care provider with a copy of your signed and dated letter for your records. Retain a copy for yourself and each person named as an authorized person in the letter.
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