Confidential · Encrypted

HIPAA Authorization

This authorization permits TRIBUTE Elder Care Consulting to request and receive your protected health information from the providers you list below.

Patient information

Full legal name

Date of birth

Mailing address

Phone

Personal representative (optional)

If a family member or POA is completing this on the patient's behalf.

Representative's name

Relationship / authority

Authorization scope

Providers we may contact

Purpose of disclosure

Authorization expires

Most clients choose 12 months from today. You may revoke earlier in writing at any time.

I understand that information disclosed under this authorization may be re-disclosed by the recipient and is no longer protected by federal privacy regulations once re-disclosed.I understand I may revoke this authorization in writing at any time, except to the extent action has already been taken in reliance on it.

Signature

Type your full legal name to sign

Date

Signature preview

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Submitted securely. A signed copy is logged with our practice.