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)**

**1. Authorization**
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. **