HIPAA Authorization to Disclose Protected Health Information

AUTHORIZATION FOR USE OR DISCLOSURE OF
PROTECTED HEALTH INFORMATION
(45 CFR § 164.508)

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SECTION 1 — PATIENT (INDIVIDUAL WHOSE PHI WILL BE DISCLOSED)
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Name:               Jordan Alex Taylor
Date of birth:      June 12, 1985
Address:            482 Elm Street, Apt 3B, Portland, OR 97214
Phone:              +1 503 555 0118
Medical record #:   MRN-PNW-44218

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SECTION 2 — COVERED ENTITY AUTHORIZED TO DISCLOSE
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Name:               Pacific NW Family Medicine, PLLC
Address:            925 NW 19th Ave, Portland, OR 97209

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SECTION 3 — RECIPIENT(S) AUTHORIZED TO RECEIVE PHI
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Name:               Acme Clinical Research, Inc.
Address:            1500 Research Blvd, Bethesda, MD 20892
Relationship:       Research sponsor (no prior treatment relationship)

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SECTION 4 — DESCRIPTION OF PHI
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The following information is authorized for use or disclosure:

Complete medical record from January 1, 2023 through the date of this authorization, including: (a) physician progress notes; (b) laboratory results; (c) imaging reports; (d) medication history; (e) immunization records; (f) discharge summaries from any inpatient stays.
(Strike or modify any category you do NOT wish to authorize.)

Sensitive categories — only those initialed below are authorized:

____ HIV/AIDS testing and treatment records.
____ Mental health diagnosis and treatment records (other than psychotherapy notes — see separate authorization).
____ Substance use disorder treatment records (42 CFR Part 2 — see separate authorization required).
____ Genetic testing results.
____ Reproductive and sexual health records.

NOTE: Substance use disorder records protected by 42 CFR Part 2 require
a separate Part 2-compliant consent. Psychotherapy notes (45 CFR
164.508(a)(2)) require a separate authorization that may not be
combined with any other authorization.

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SECTION 5 — PURPOSE OF USE OR DISCLOSURE
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Purpose:            At the request of the individual

If "Other": Not applicable.

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SECTION 6 — EXPIRATION
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This authorization expires on:

  Type:             Date certain
  Specific date:    May 8, 2027
  Or event:         Completion of clinical encounter for which records are requested.

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SECTION 7 — REQUIRED STATEMENTS (45 CFR § 164.508(c)(2))
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(a) RIGHT TO REVOKE. I understand that I may revoke this authorization
at any time by submitting a written revocation to the privacy officer
of the covered entity named in Section 2. The revocation will not
apply to any disclosures already made in reliance on this authorization
prior to receipt of the revocation. Revocation of an authorization for
research may be limited to the extent the covered entity has acted in
reliance on the authorization.

(b) TREATMENT NOT CONDITIONED. I understand that the covered entity
generally may not condition my treatment, payment, enrollment in a
health plan, or eligibility for benefits on whether I sign this
authorization, except as permitted under 45 CFR 164.508(b)(4):
(i) research-related treatment; (ii) eligibility/enrollment determinations;
(iii) underwriting; (iv) when the only purpose of treatment is to
disclose PHI to a third party.

(c) RE-DISCLOSURE. I understand that information used or disclosed
pursuant to this authorization may be subject to re-disclosure by the
recipient and is no longer protected by federal HIPAA privacy rules.
However, certain categories (substance use disorder under 42 CFR Part 2;
genetic information under GINA) retain federal protection against
re-disclosure even after disclosure to a non-covered entity.

(d) MARKETING / SALE OF PHI. If purpose is marketing AND covered entity will receive direct or indirect remuneration: I acknowledge that the covered entity will be paid by the recipient for this authorization.
If purpose is sale of PHI: I acknowledge that this authorization will result in remuneration to the covered entity.
(Strike if neither applies.)

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SECTION 8 — SIGNATURE
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I have read this authorization and understand my rights. I am signing
voluntarily.


_____________________________________     May 11, 2026
Patient (or personal representative)      Date

Signed by:          No — signed by patient
If representative:  Not applicable.
                    (Personal representative must attach documentation
                     of authority — court order, power of attorney, etc.)

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COPY TO PATIENT
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The covered entity must provide a copy of the signed authorization to
the patient (45 CFR § 164.508(c)(4)).