Laserfiche WebLink
HIPAA Privacy Rule Authorization <br />for Release of Health Information <br />I, <br />(Employee Name) <br />protected health information as follows: <br />authorize the specified person(s) to disclose <br />1. Person authorized to make disclosure: Elk River Municipal Utilities Health Care <br />Plan. <br />2. Person authorized to receive the disclosed information: Elk River Municipal <br />Utilities. <br />3. Specific description of the protected health information that may be used or <br />disclosed: <br />4. I understand that the information received pursuant to this authorization may be <br />disclosed by° the recipient and might lose its protected status. <br />5. I understand that I may revoke this authorization at any time by giving written <br />notice to <br />(Financial Director) <br />6. I understand that I am entitled to receive a copy of this authorization. <br />7. I understand that after this information is disclosed, federal law might not protect it <br />and the recipient might re-disclose it. <br />S. I understand that my initial and continued employment and position are subject to <br />my agreement to this authorization, and any additional authorization Elk River <br />Municipal Utilities requests. <br />9. I understand that this authorization will expire when my employment with Elk River <br />Municipal Utilities terminates or when I am no longer covered by the company's <br />employee benefits plan or COBRA plan, whichever is later. <br />Signature of Employee: <br />Name: <br />Date: <br />If a Personal Representative executes this form, that Representative warrants that he or <br />she has authority to sign this form on the basis of: <br />(Description of personal representative's authority) <br />