HIPAA Privacy Authorization Form
Authorization for Use of Protected Health Information (PHI)
Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164
In submitting a request for help using one of Full Strength Network’s Request for Help forms, I authorize Full Strength Ministries, Inc., DBA Full Strength Network (healthcare provider) to store, retrieve, and use (hereafter, “Use”) my protected health information for the purposes of providing me wellbeing services.
This authorization for Use of information covers the period of healthcare for all past, present, and future periods.
Extent of Authorization
I authorize the Use of my complete health record.
This medical information may be Used by all employees, agents, and authorized personnel to receive this information for medical treatment or consultation, billing or claims payment, or for other purposes as I may direct.
This authorization shall be in force in until I revoke it in writing. I understand that I have the right to revoke this authorization in writing at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
I understand that information Used pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.