REQUIRED ELEMENTS

PRESENT?

A description of the information to be used or disclosed that identifies the information in a specific and meaningful fashion

¨ Yes

¨ No

The name or other specific identification of the person(s), or class of persons, authorized to make the requested use or disclosure.

¨ Yes

¨ No

The name or other specific identification of the person(s), or class of persons, to whom the covered entity may make the requested use or disclosure.

¨ Yes

¨ No

A description of each purpose of the requested use or disclosure.

¨ Yes

¨ No

An expiration date or an expiration event that relates to the individual or the purpose of the use or disclosure.

¨ Yes

¨ No

Signature of the individual and date.

¨ Yes

¨ No

Has the client revoked the authorization?

¨ Yes

¨ No

Has the client placed other conditions on the authorization?

¨ Yes

¨ No