HIPAA AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION This form is for use when such authorization is required and complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards. "*" indicates required fields Name First Last Date of Birth MM slash DD slash YYYY Email* SSN#PhoneAuthorizationI authorize the Office of Dr. Christopher N. Siachos, to use of disclose my health information to the following persons:Name: Name: Name: My RightsI understand that I have the right to revoke this authorization, in writing, at any time except where uses or disclosures have already been made based upon my original permission. I may not be able to revoke this authorization if its purpose was to obtain insurance. In order to revoke this authorization, I must do so in writing and send it to the appropriate disclosing party. I understand that uses and disclosures already made based upon my original permission cannot be taken back. I understand that it is possible that information used or disclosed with my permission may be re-disclosed by the recipient and is no longer protected by the HIPAA Privacy Standards. I will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original.Today's Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Is the patient a minor? Yes No Is the patient unable to sign? Yes No If the patient is a minor, how many years of age? If the patient is unable to sign, please explain why: NameThis field is for validation purposes and should be left unchanged.