HIPAA Privacy Authorization Form for DocuTrac Support

Pursuant to a Business Associate Agreement by and between "Covered Entity", as below, and DocuTrac, Inc. "Business Associate" as required by the Health Insurance Portability and Accountability Act, 45 C.F.R.Parts 160 and 164 the parties hereby agree to the following:

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.


Agency or Practice Name:

EMail Address:

Effective Date:

  I    am authorized by the Covered Entity named above to give consent to this Authorization.

  I hereby authorize the viewing or transfer of patient data as described above.