CHA HIPAA Authorization Form Christian Health Aid HIPAA Authorization Form Patient's Full Name Address City State AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Zip Patient's Social Security Number Medical Record Number Patient's Date of Birth Patient's Telephone Number I hereby authorize physicians, hospitals, and other medical personnel to disclose protected health information about me to Christian Health Aid/Century Health Alliance for the purpose of determining eligibility and negotiating reductions in bills and for potential bill sharing payments. UNLESS YOU SIGN HERE, NO INFORMATION ABOUT ALCOHOL/SUBSTANCE ABUSE, HIV/AIDS, OR MENTAL HEALTH WILL BE DISCLOSED: YES, Disclose this information signature keyboard Clear NO, DO NOT Disclose this information signature keyboard Clear 1. I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it,and would then no longer be protected by federal privacy regulations.2. I may revoke this authorization by notifying the provider/hospital/medical personnel in writing of my desire to revoke it. However, Iunderstand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.3. This authorization will expire upon termination of Patient's membership in CHA, unless revoked in writing. OR, if applicable - Signature of Individual signature keyboard Clear Signature of Responsible Party signature keyboard Clear Email Address (for sending your personal copy) Description of Authority to Act for the Individual (e.g., parent/guardian) Submit If you are human, leave this field blank.