I hereby authorize the use and disclosure of individually identifiable health information relating to me, otherwise known as “protected health information” or “PHI” under a federal privacy law, as described below. I understand this authorization is voluntary. I consider a copy of this authorization to be valid as the original. I understand that if the organization authorized to receive the information is not a health plan or healthcare provider, the released information may no longer be protected by federal privacy regulations.
SPECIFIC AUTHORIZATION FOR RELEASE OF INFORMATION PROTECTED BY STATE OR FEDERAL LAW
I specifically authorize the release of data and information relating to (please initial appropriate box below and hereby release Neurology Consultants of Nebraska, P.C. from all legal liability that might arise from the release of sensitive information protected by Title 42 of the Code of Federal Regulations.
*Substance Abuse (alcohol or drug abuse)
*Behavioral Health (except psychotherapy notes which require a specific authorization)
*HIV or other Sexually Transmitted Disease Related Informaitons (or AIDS related testing)
I understand that I may revoke this authorization at any time, except to the extent that action has already been taken to comply with it, by writing to:
Neurology Consultants of Nebraska, P.C.
North Doctors Tower
4242 Farnam, Suite 500
Omaha, NE 68131
Without my written permission to revoke this authorization, it will automatically expire six months from the date of signature according to Nebraska Law.
If you desire a specific date (not to exceed six (6) months), or event upon which this authorization will expire, please specify:
I understand that I am entitled to a copy of this authorization form. I understand that I have the right to inspect or receive copies of my Protected Health Information (PHI) to be used and/or disclosed under this authorization, and that a fee for copies may be imposed by Neurology Consultants of Nebraska, P.C. or its designated Business Associate.
Recipient Please Note: This information may have been disclosed to you from records whose confidentiality is protected by federal law. Federal regulation (42 C.F.R. Part 2) prohibits you from making any further disclosure without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations.
