HIPAA Release and Authorization (Authorized Individual)
Effective January 7th 2026
3200 Cross Creek Pkwy
Auburn Hills, MI 48326
Phone: 248-520-5407 Fax: 888-844-4901
HIPAA RELEASE AND AUTHORIZATION
***Patients: Please use this form to list any family members or additional doctors that you would like us to be able to discuss/share your medical information with. For example, if you want us to be able to share test results with your spouse you must fill out this form. Please print additional copies of this form for each individual or doctor.
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I hereby authorize the following person to act as my agent with regard to the matters specified in this Release:
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This Release and all the provisions contained herein are effective immediately. I intend for my agent to be treated as I would be treated with respect to my rights regarding the use and disclosure of my individually identifiable health information and other medical records. This Release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. Sections 1320d to 1320d-9 and 45 C.F.R. Sections 164.500 to 164.534, as may be amended from time to time.
I hereby authorize Transcend Company, Inc. to give, disclose and release to my agent who is named herein and who is currently serving as such and without restriction, all of my individually identifiable health information and medical records regarding any past, present or future medical or mental health condition, including all information relating to the diagnosis and treatment of HIV/AIDS, sexually transmitted diseases, mental illness, and drug or alcohol abuse. Additionally, this disclosure shall include the ability to ask questions and discuss this protected health information with the person or entity who has possession of the protected health information even if I am fully competent to ask questions and discuss this matter at the time. It is my intention to give a full authorization to access any protected health information to my agent. Health information and medical records as indicated above shall be released at my request or at the request of my agent named herein as may be needed to assist in my treatment, make decisions about my care or for any other reason, at my discretion or at the discretion of my agent.
The authority given to my agent shall supersede any prior agreement that I may have made with my health care providers to restrict access to or disclosure of my individually identifiable health information. The individually identifiable health information and other medical records given, disclosed, or released to my agent may be subject to re-disclosure by my agent and may no longer be protected by HIPAA.
This Release shall terminate on the first to occur of: (i) two years following my death, or (ii) my written revocation actually received by Transcend Company, Inc. Proof of receipt of my written revocation may be by certified mail, registered mail, facsimile, electronic mail, or any other means evidencing actual receipt by the covered entity. This Release shall not be affected by my subsequent disability or incapacity. There are no exceptions to my right to revoke this Release.
Transcend Company, Inc., acting in reliance on this Release shall be released from liability that may result from disclosing my individually identifiable health information and other medical records.
Copies or facsimiles of this Release shall be as valid as the original Release.
Patient Signature: |
Date Signed: |
