Patient Online Forms

HIPAA Privacy Authorization Form

Authorization for Use or Disclosure of Protected Health Information

(Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)

1. Authorization

I authorize Premier medical Associates to use and disclose the protected health information described below

2. Effective Period

This authorization for release of information covers the period of healthcare from:



3. Extent of Authorization