HIPAA Authorization Form — Martinez Heart & Home Care

⚠️ Important — Read Before Completing This is a voluntary authorization. You have the right to refuse to sign this form. Refusing to sign will not affect your ability to receive treatment or services from Martinez Heart & Home Care, except where the disclosure is necessary to provide the requested service. You may revoke this authorization at any time in writing, except to the extent that action has already been taken in reliance on it.

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Authorization Submitted

Your HIPAA Authorization has been received and securely recorded. A copy will be provided to you upon request.

Reference #: HIPAA-000000

Please retain this reference number for your records. You may revoke this authorization at any time by contacting us in writing at (XXX) XXX-XXXX or privacy@martinezheartandhomecare.com.

Patient / Client Information

Patient First Name * Required.

Patient Last Name * Required.

Date of Birth * Required.

Phone Number * Enter a valid phone number.

Home Address * Required.

Email Address (optional)

Medicaid / Insurance ID (if applicable)

Person Completing This Form (if not the patient)

ℹ️ Complete this section only if you are signing on behalf of the patient If you are the patient, skip to Section 3. If you are a legal guardian, healthcare power of attorney, or authorized representative, complete this section and attach proof of authority.

Representative Full Name

Relationship to Patient

Representative Phone

Authority Document on File

Section 3: Who May Receive My Health Information

I authorize Martinez Heart & Home Care to disclose my protected health information to the following person(s) or organization(s):

Recipient 1 — Name / Organization * Please enter at least one recipient.

Recipient 1 — Relationship / Purpose

Recipient 1 — Phone / Fax (optional)

Additional Recipients (optional)

Recipient 2 — Name / Organization

Recipient 2 — Relationship

Recipient 3 — Name / Organization

Recipient 3 — Relationship

Section 5: Purpose of Disclosure

🤝 Coordination of Care — Share information with my healthcare team to coordinate my home care services 💳 Insurance / Medicaid Billing — Authorize billing and payment processing for home care services 👨‍👩‍👧 Family / Caregiver Communication — Allow family members or caregivers to receive health updates 🏛️ DSHS / Case Management — Share with DSHS case manager for Medicaid home care authorization 🏥 Referral to Another Provider — Transfer care information to a specialist or other healthcare provider 👤 At My Request — I am requesting this disclosure for my own purposes 💬 Other — Specify below

Please select a purpose.

Additional Purpose Details (optional)

Section 6: Expiration of This Authorization

This authorization will expire on: *

📅 1 Year from Date of Signing (recommended) 📅 6 Months from Date of Signing ✅ Upon Completion of the Requested Disclosure 🏠 Upon Termination of Home Care Services 📆 Specific Date:

Please select an expiration option.

Section 7: Your Rights — Please Read

🔒 Your HIPAA Rights Regarding This Authorization

Right to Revoke: You may revoke this authorization at any time by submitting a written request to Martinez Heart & Home Care. Revocation will not affect actions already taken in reliance on this authorization.
Right to Refuse: You may refuse to sign this authorization. Refusal will not affect your ability to receive treatment, except where the disclosure is necessary to provide the requested service.
Re-disclosure Risk: Information disclosed pursuant to this authorization may be re-disclosed by the recipient and may no longer be protected by HIPAA.
Sensitive Information: Mental health records, substance use records, and HIV/AIDS status have additional legal protections. Authorizing their disclosure requires your specific consent.
Copy of Authorization: You are entitled to receive a copy of this signed authorization upon request.
Washington State Law: This authorization is also governed by the Washington State Health Care Information Act (RCW 70.02), which may provide additional protections.

Section 8: Electronic Signature

✅ Electronic Signature Notice By signing below, you acknowledge that your electronic signature has the same legal effect as a handwritten signature under the Washington State Electronic Authentication Act (RCW 19.34) and the federal Electronic Signatures in Global and National Commerce Act (E-SIGN Act, 15 U.S.C. §7001).

Signer's Full Legal Name * Required.

Date of Signature * Required.

Signing Capacity * Required.

Draw Your Signature Below *

Draw with mouse or touch

Please provide your signature.

Typed Signature (alternative to drawn) (optional if drawn above) Typing your name here constitutes your legal electronic signature if no drawn signature is provided.

🔒 Encrypted • Secure • HIPAA-Compliant • You will receive a reference number upon submission

HIPAA Authorization for Use & Disclosure of Health Information

🔒 HIPAA Authorization Form

Authorization Submitted