Authorization Form
(Consent for Release of Confidential Information)

This form when completed and signed by you, authorizes me to release protected information from your personal record to the person you designate.

I authorize my coach, and/or his or her administrative and professional staff, or associates, to release (Provide description of the information that you want disclosed. Your description should be as specific and detailed as possible.)

This information should only be released to (name and address of person to whom the information is to be released)

I am requesting my coach to release this information for the following reasons: (“at the request of the individual” is all that is required if you are my patient and you do not desire to state a specific purpose.)

This authorization shall remain in effect until (fill in expiration date) or until (fill in an event that relates to the individual or the purpose of the use or disclosure).

You have the right to revoke this authorization, in writing, at any time by sending such written notification to my office address. However, your revocation will not be effective to the extent that I have taken action in reliance on the authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

I understand that my coach generally may not condition coaching services upon my signing an authorization unless the services are provided to me for the purpose of creating health information for a third party.

I understand that information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient of your information and no longer protected by the HIPAA Privacy Rule.
______________________________ _________________
Signature of Patient Date
If the authorization is signed by a personal representative of the patient, a description of such representative’s authority to act for the patient must be provided.

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