This form complies with the Federal Health Insurance Portability and Accountability Act (HIPAA). This is a secure form; the information that you enter here will be seen only by the staff of our practice.

Directions: fill out all applicable fields and submit the form. We will contact you if there are any concerns or errors with your submission.
 

I request and authorize Hear Virginia to disclose my protected health information as described below. I understand that if the person/organization authorized to receive and use the information is not a health plan or health care provider, the disclosed information may no longer be protected by federal privacy regulations.

 I consent to Hear Virginia releasing protected health as detailed below.

My protected health information may be used or disclosed to the following persons

List Name and Relationship

for the Purpose of: Hearing Health, Hearing Aid Care and Maintenance

If you need assistance in completing the authorization form, please contact Carolyn Halbert at cchalbert@hear-virginia.com.

I understand that I have the right to request restrictions as to how my protected health information may be used or disclosed by Hear Virginia. I understand that this authorization is in effect until the revocation section of this form is signed or until written notice of revocation is received. I may revoke this authorization at any time by signing the revocation section of my copy of this form and returning it to Hear Virginia.

I authorize Hear Virginia's use and disclosure of my protected health information as set forth above. I understand that this authorization is voluntary and that Hear Virginia cannot condition my treatment, services, etc... on the signing of this authorization. I understand that if I am signing on behalf of a minor child, this authorization will expire upon the child reaching the age of 18, unless there is proof of legal guardianship.