Step 2 · Medical Records Release

CCA HIPAA Authorization 2026

Authorize medical providers, pharmacies, clinics, hospitals, and social service agencies to release information needed for financial or medical assistance.

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

Including Disclosure of Protected Health Information pursuant to the Health Insurance Portability and Accountability Act ("HIPAA") and 45 C.F.R. § 164.508

Patient Information

Date of Birth Address City State ZIP Telephone

I hereby authorize Community Cancer Association to receive or release information from the medical records of:

Patient Name

Authorization Details

To Pharmacies, Physicians' offices, Clinics, Hospitals, Social Service Agencies, etc.

For the purpose of providing or obtaining Financial/Medical Assistance.

Time Frame of Requested Information: Birth to Present

I understand that the protected health information described above may be re-disclosed and no longer protected by federal and state privacy regulations. However, I understand that the recipient may be prohibited from disclosing substance abuse information under the Federal Substance Abuse Confidentiality requirements.

Revocation of Authorization: I understand that l may revoke this authorization in writing at any time. I understand that I may revoke this authorization by sending or faxing a written notice to Community Cancer Association. This written revocation must state my intent to revoke this authorization. However, I understand that any actions already taken in reliance on this authorization cannot be reversed, and any revocation will not affect those actions.

Any facsimile, copy or photocopy of this authorization shall be as valid as the original.

Time limit on Authorization: This authorization shall be effective until it is revoked.

Signature of Patient or Patient Legal Representative

Type your full name as your signature. File uploads are not accepted.

Date Printed Name of Legal Representative (if any) Representative Authority to Act for Patient (if applicable)

Fields marked * are required. Rather do this by phone? Call (254) 202-8082.