HIPAA Privacy Authorization Form
**Authorization for Use or Disclosure of Protected Health Information
(Required by the Health Insurance Portability and Accountability Act, 45 C.F.R.
Parts 160 and 164)**

1. AUTHORIZATION
   I authorize PROMISING OUTLOOK (healthcare provider) to use and disclose the protected health information described below.
2.  EFFECTIVE PERIOD
   ALL, PAST, PRESENT, AND FUTURE PERIODS
3. EXTEND OF AUTHORIZATION
   I authorize the release of my complete health record (including records relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse).
4. This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purses as I may direct.
5. This authorization shall be in force and effective until I discharge, at which time this authorization expires.
6. I understand that I have the right to revoke this authorization, in writing, at any time.
7. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.
8. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.