HIPPA FORM
Authorization for Release of Information
Purpose of Disclosure:
This authorization allows for the mutual exchange of information regarding The Client (Signed Below)
between EC Caucci, Disability Advocate at Hamesh DAAC, and medical/surgical providers and
team at any associated clinics pertaining to the services Hamesh will provide. This will include information related to any upcoming appointments or scheduled surgeries and related insurance and billing matters.
Information to be Disclosed:
The information to be shared may include, but is not limited to:
- Medical history
- Treatment plans and related communication
- Insurance documentation and coding
- Other relevant information as it pertains to advocacy and support in seeking insurance
approval for all medical procedures.
Expiration of Authorization:
This authorization will expire on the following date: 2/26/26 or upon the completion of the
purpose for which it was granted, whichever comes first. If no date is provided, this authorization
will expire one year from the date signed.
Right to Revoke:
Katharine has the right to revoke this authorization at any time by providing a written notice to
the authorized parties. However, the revocation will not affect any actions taken prior to the
receipt of the revocation.
Signature:
I, Katharine Cook, hereby authorize the exchange of my protected health information as
described above.