Data Privacy & Disclosure
Authorization Form
HIPAA, the Health Insurance Portability and Accountability Act, requires that all medical providers and their affiliates put in placecontrols to ensure that personal medical information is secured. The purpose of this form is to grant Compulink authorization of disclosure of Protected Health Information. (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)
- The medical information may be used by the organization I authorize to receive this information for assisting me with data extraction from Compulink Cloud Services.
- The release of information covers all past, present, and future periods, unless otherwise stated by me.
- This authorization shall beinforce and effect until I inform Compulink of my intention to sever my partnership with the organization receiving this information.
- I have the right to withdraw permission for the release of this information. If I sign this authorization to use or disclose information, I can revoke that authorization at any time. The revocation must be made in writing and will not affect information that has already been used or disclosed.
I hereby authorize Compulink Business Systems, Inc. and its affiliates, employees and agents to disclose Protected Health Information to: