HIPAA Waiver
I. Introduction
This HIPAA Waiver ("Waiver") is entered into by and between [YOUR COMPANY NAME], located at [COMPANY ADDRESS], and [PARTICIPANT'S NAME] ("Participant"). This Waiver governs the release and disclosure of protected health information (PHI) as defined by the Health Insurance Portability and Accountability Act (HIPAA) for the purposes outlined herein.
II. Purpose
The purpose of this Waiver is to authorize the disclosure of Participant's PHI for specific purposes as outlined below.
III. Authorization
Participant hereby authorizes [YOUR COMPANY NAME] to disclose their PHI as follows:
[Purpose 1]: [Description of purpose 1]
[Purpose 2]: [Description of purpose 2]
[Purpose 3]: [Description of purpose 3]
IV. Scope of Information
Participant understands and agrees that the PHI disclosed pursuant to this Waiver may include, but is not limited to, medical records, treatment history, diagnostic tests, and other health-related information.
V. Parties' Responsibilities
[YOUR COMPANY NAME] agrees to:
Safeguard the confidentiality and security of the disclosed PHI.
Limit the use and disclosure of PHI to the purposes outlined in this Waiver.
Comply with all applicable laws and regulations, including HIPAA and any state or federal privacy laws.
Participant agrees to:
VI. Duration
This Waiver shall remain in effect until [SPECIFY END DATE OR EVENT], unless revoked earlier by Participant in writing.
VII. Revocation
Participant reserves the right to revoke this Waiver at any time by providing written notice to [YOUR COMPANY NAME]. However, revocation shall not affect any disclosures made prior to the receipt of such notice.
VIII. Acknowledgment
By signing below, Participant acknowledges that they have read and understood the terms of this Waiver, and voluntarily consent to the disclosure of their PHI as outlined herein.
IX. Signature
In Witness Whereof, the parties have executed this Waiver as of the date indicated below.
Participant's Signature:
Printed Name: [PARTICIPANT'S NAME]
[Date]
[YOUR COMPANY NAME] Representative's Signature:
Printed Name: [YOUR NAME]
[Date]
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