Authorization to View or Transfer Protected Health Information (PHI)
1. Authorization: Covered Entity authorizes the viewing of PHI and/or
the transfer of PHI in database format for the specific purpose of information
technology computer software support. This service is provided by the Business
Associate's support and/or development personnel.
2. Effective Period :This authorization for release of information
covers the period of time from: The effective date, as below, until the
technical support issue is resolved in agreement by both parties.
3. The Business Associate understands the confidential nature of this
PHI, and bound by the HIPAA Privacy and Security Rules contained the Act stated
above, is responsible for the data's security and disposal pursuant to the afore
mentioned Business Associate Agreement.
Attestation:Agency or Practice Name: EMail Address: Effective Date: I am authorized by the Covered Entity named above
to give consent to this Authorization.
authorize the viewing or transfer of patient data as described above.