HIPAA AUTHORIZATION FORM

I,__________________________________________ (please print), give permission to American University of Health Sciences to disclose the following protected health information to: Prospective Clinical Sites (TBD).

Information to be disclosed (check all that apply):

✓ Medical Records
✓ Treatment Records
✓ Diagnostic Records
✓ Titers

Please read and initial the following statements:

____ This protected health information is being used or disclosed to determine clinical clearance.
____ This authorization expires upon the completion of the program.
____ You may refuse to sign this authorization; however, doing so will prevent clinical clearance.
____ You may inspect or copy the protected health information to be used or disclosed under this authorization.
____ You may revoke this authorization in writing at any time by submitting written notification to American University of Health Sciences at 1600 E. Hill St., Signal Hill, CA 90755.
____ Your signature below indicates your understanding and agreement of the aforementioned:

__________________________                  ___________________________

Printed Name                                                 Student Signature

__________________________

Date