CHA HIPAA Authorization Form Christian Health Aid HIPAA Authorization Form Patient's Full Name Address City State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY 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 payment. UNLESS YOU SIGN HERE, NO INFORMATION ABOUT ALCOHOL/SUBSTANCE ABUSE, HIV/AIDS, OR MENTAL HEALTH WILL BE DISCLOSED: YES, Disclose this information Clear NO, DO NOT Disclose this information 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, I understand 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 in one (1) year unless revoked in writing. OR, if applicable - Signature of Individual Clear Signature of Responsible Party Clear Email Address (for sending your personal copy) Description of Authority to Act for the Individual (e.g., parent/guardian) Submit