FORM 22 - Use with Questions 22-23. Provide a separate Form 22 for each treatment provider. HIPAA Privacy Authorization Form Authorization for Use or Disclosure of Protected Health Information (Require d by the H ealth Insuranc e Portab ility and Acco untability Act - 45 CFR P arts 160 a nd 164 .) (Applicant/Patient’s Full Name) (1) (Date of Birth) (SSN) I hereby authorize (list the Name and Address of Health Care Provider below): to disclose the protected health information described below to: Missouri Board of Law Examiners, 1700 Jefferson Street, Jefferson City, MO 65109. (2) I permit the release of all information, including test results and/or diagnosis and treatment information, if any, concerning drug/alcohol treatment or use, psychiatric treatment, or AIDS/HIV and other communicable diseases. (3) The date(s) of treatment covered by this Authorization are: (4) This medical information may be used by the Missouri Board of Law Examiners for the purpose of investigating and evaluating my character and fitness to be licensed to practice of law. (5) I understand that once this information has been released pursuant to this Authorization, it may no longer be protected by Federal and State law and may no longer be deemed “Confidential.” (6) I understand that the health care provider to whom this Authorization is directed will not condition my treatment, billing, or enrollment or eligibility for health insurance benefits on whether I sign this Authorization. (7) I understand that I may revoke this Authorization at any time except to the extent that prior action has been take in reliance on it. This Authorization will expire six months after the date it is signed if I do not cancel it in writing prior to the expiration date. Date: ___________ ______ Signature of Applicant Subscribed and sworn to before me this ______ day of __________________________, 20______. Signature of Notary Public [Seal or Stamp must be affixed to each original] American LegalNet, Inc. www.FormsWorkflow.com