HIPAA Privacy Authorization
**Authorization for Use or Disclosure of Protected Health Information
(Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)**
I authorize Top Notch Hearing to use and disclose the protected health information described below with the manufacture of the hearing aids.
**2. Effective Period**
This authorization will remain in effect until terminated by me in writing
**3. Extent of Authorization**
This authorization shall include but not be limited to audiometric test scores, otoscopy, or any other health conditions and / or considerations pertaining to the ear or auitory system.
**4. This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.**
**5. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. **
**6. I understand that information used or disclosed pursuant
to this authorization may be disclosed by the recipient
and may no longer be protected by federal or state law. **