Serving Hamilton, Butler, Clermont & Warren Counties

HIPAA Authorization Form

HIPAA

Authorize BridgeCare to use or disclose your protected health information. All fields marked * are required.

(513) 587-4923 [email protected]

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1Client Information

Full Name*

Date of Birth*

Street Address

City

State

ZIP Code

Phone Number

Email Address

2Authorized Person or Organization

I authorize BridgeCare to disclose my health information to:

Name of Authorized Person / Organization*

Relationship to Client*

Phone Number

3Authorization Details

Purpose of Disclosure*

Information to Disclose*

Expiration Date (optional)

4Rights & Acknowledgement

Your Right to Revoke

You have the right to revoke this authorization at any time by submitting a written request to BridgeCare. Revocation will not affect any disclosures already made in reliance on this authorization.

I understand and acknowledge my right to revoke this authorization at any time. *

5Electronic Signature

By typing your full name below, you authorize BridgeCare to use and disclose your health information as described above.

Electronic Signature (Type Full Name)*

Date*

Your submission will be sent securely to our team at [email protected]. A completed PDF copy will be available for download after submission.