☐ PART C - HIPAA
HIPAA Privacy Authorization Form Authorization for Use or Disclosure of Protected Health Information (Required
by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)
1. Authorization I authorize____________________________________ (name of doctor, hospital or Speech
Language Pathologist), to use and disclose the protected health information described below to
Communication Advisors/Staff of sComm.
2. Effective Period This authorization for release of information covers the period of healthcare from:
_____________________ to: _____________________ (Period of 12 months from current date).
3. I authorize sComm to discuss and receive my information for purposes of a referral for evaluation by a
Speech Language Pathologist for Durable Medical Equipment for Communication.
4. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a
revocation is not effective to the extent that any person or entity has already acted in reliance on my
authorization or if my authorization was obtained as a condition of obtained as a condition of obtaining
insurance coverage and the insurer has a legal right to contest a claim.
5. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on
whether I sign this authorization.
6. I understand that information used or disclosed pursuant to this authorization may be disclosed by the
recipient and may no longer be protected by federal or state law.
☐ PART D – Patient Agreement
I, _________________________________________ understand and voluntarily agree that:
I will keep (and be on time for) all scheduled appointments with the Primary Care
Provider PCP (Family Doctor), and Speech Language Pathologist SLP. If I need to
reschedule for a good reason, I am responsible to notify Communication Access
Advisor to reschedule the appointments. One PCP appointment is excused and one
SLP appointment is excused.
If I cancel 2nd PCP and/or SLP appointment(s), I am fully responsible to make a call to reschedule the appointments