AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION

Pursuant to the Health Insurance Portability and Accountability Act (HIPAA)

I. PATIENT INFORMATION

Full Legal Name: ______________________________________
Date of Birth: //________
Address: ____________________________________________
City, State, Zip: ______________________________________
Phone Number: (___) -
Email Address: _______________________________________
Medical Record Number: ______________________________
Other Identifier (if applicable): _________________________

II. AUTHORIZATION

I hereby authorize the use and/or disclosure of my protected health information as described below. I understand that this authorization is voluntary and that I may refuse to sign it. I further understand that my treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my providing this authorization except in limited circumstances as permitted by law.

III. AUTHORIZED RECIPIENTS

I authorize the following person(s) and/or organization(s) to receive my protected health information:

Recipient 1:
Name/Organization: ______________________________________
Relationship to Patient: ___________________________________
Address: _______________________________________________
City, State, Zip: _________________________________________
Phone Number: (___) -
Email Address: _________________________________________

Recipient 2:
Name/Organization: ______________________________________
Relationship to Patient: ___________________________________
Address: _______________________________________________
City, State, Zip: _________________________________________
Phone Number: (___) -
Email Address: _________________________________________

Recipient 3:
Name/Organization: ______________________________________
Relationship to Patient: ___________________________________
Address: _______________________________________________
City, State, Zip: _________________________________________
Phone Number: (___) -
Email Address: _________________________________________

IV. PURPOSE OF DISCLOSURE

The protected health information is being disclosed for the following purpose(s): (Check all that apply)

□ At the request of the patient or personal representative
□ Continuity of medical care
□ Insurance/benefits eligibility or claims
□ Legal proceedings or representation
□ Disability determination
□ Workers' compensation
□ Personal records/use
□ Other (specify): _______________________________________

V. INFORMATION TO BE DISCLOSED

A. Scope of Information
(Check all that apply)

□ Complete medical record
□ Hospital/inpatient records
□ Outpatient/clinic records
□ Emergency department records
□ Laboratory results
□ Radiology/imaging reports
□ Pathology reports
□ Consultation reports
□ Progress notes
□ Physician orders
□ Nursing notes
□ Medication records
□ Immunization records
□ Billing and payment records
□ Other (specify): _______________________________________

B. Date Range of Records
(Check one)

□ All records regardless of date
□ Records from //______ to //______
□ Records created up to and including the date of this authorization
□ Records created after the date of this authorization until its expiration
□ Other (specify): _______________________________________

C. Sensitive Information
I understand that certain types of sensitive health information require specific authorization for disclosure. By initialing below, I specifically authorize the disclosure of the following types of sensitive information (if such information exists in my records) for the time period specified above:

_____ Mental health treatment information (excluding psychotherapy notes)
_____ Substance use disorder diagnosis, treatment, or referral information
_____ HIV/AIDS testing, diagnosis, or treatment information
_____ Sexually transmitted disease information
_____ Genetic testing/information
_____ Reproductive health information (including abortion records)
_____ Domestic/sexual violence information

Note regarding Psychotherapy Notes: This authorization DOES NOT include permission to release psychotherapy notes. Under HIPAA, psychotherapy notes are defined as notes recorded by a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session that are kept separate from the rest of the medical record. Release of psychotherapy notes requires a separate authorization form.

VI. TIME LIMITATIONS AND EXPIRATION

This authorization will remain in effect: (Check one)

□ From the date of this authorization until: //______
□ Until the following event occurs: _________________________
□ For one (1) year from the date of signature below
□ Until the purpose of the disclosure is fulfilled
□ Other (specify): _______________________________________

VII. YOUR RIGHTS REGARDING THIS AUTHORIZATION

A. Right to Revoke: I understand that I have the right to revoke this authorization, in writing, at any time by sending written notification to:

I understand that my revocation will not be effective to the extent that action has already been taken in reliance on this authorization, or if this authorization was obtained as a condition of obtaining insurance coverage and the law provides the insurer with the right to contest a claim under the policy or to contest the policy itself.

B. Right to Inspect or Copy: I understand that I have the right to inspect or copy the protected health information that may be used or disclosed pursuant to this authorization, as provided in the HIPAA Privacy Rule.

C. Right to Receive Copy: I understand that I have the right to receive a copy of this signed authorization.

VIII. REDISCLOSURE NOTICE

I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient(s) and may no longer be protected by federal or state privacy laws, including HIPAA. The healthcare provider, its employees, officers, and physicians are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.

IX. TREATMENT, PAYMENT, ENROLLMENT, OR ELIGIBILITY FOR BENEFITS

I understand that Name of Healthcare Provider/Organization _________________ may not condition my treatment, payment, enrollment in a health plan, or eligibility for benefits on whether I sign this authorization, except:

1. If the authorization is for research-related treatment, in which case treatment may be conditioned on my signing this form;
2. If the purpose of the authorization is to determine my eligibility for enrollment or underwriting; or
3. If the authorization is solely for the purpose of creating protected health information for disclosure to a third party (such as pre-employment physicals or life insurance examinations).

X. POTENTIAL FOR FINANCIAL GAIN

□ I understand that Name of Healthcare Provider/Organization _________________ □ will □ will not receive direct or indirect compensation or remuneration from a third party in exchange for using or disclosing my health information.

XI. SPECIAL PROVISIONS

A. Substance Use Disorder Records (42 CFR Part 2 Compliance):
If this authorization includes the release of information related to substance use disorder diagnosis, treatment, or referral, I understand that such information is protected by federal confidentiality rules (42 CFR Part 2). These rules prohibit recipients from making any further disclosure of substance use disorder information unless further disclosure is expressly permitted by my written authorization or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any substance use disorder patient.

B. Research-Related Disclosures (if applicable):
□ This authorization is for research purposes. I understand the following:

• Description of the research: _________________________
• Potential risks and benefits: _________________________
• My right to refuse participation without affecting my care: _________________________

C. Marketing-Related Disclosures (if applicable):
□ This authorization is for marketing purposes. I understand the following:

• Description of marketing activity: _________________________
• Whether the provider will receive financial remuneration: □ Yes □ No
• My right to revoke specifically for this purpose: _________________________

XII. STATE LAW COMPLIANCE

I understand that my health information may be protected by state laws that provide more stringent protections than federal law. This authorization is intended to comply with all applicable state laws, including but not limited to laws regarding mental health, developmental disabilities, substance use disorders, communicable diseases, genetic information, and reproductive health.

XIII. PERSONAL REPRESENTATIVE INFORMATION (if applicable)

If this authorization is being signed by a personal representative of the patient:

Name of Personal Representative: _________________________
Relationship to Patient: _________________________________
Legal Authority: □ Parent of Minor □ Legal Guardian □ Power of Attorney for Healthcare □ Other (specify): _________________________

Documentation: I have attached the following documentation of my authority to act for the patient (check all that apply): □ Court Order □ Power of Attorney □ Guardianship Papers □ Other: _________________________

XIV. MINOR PATIENT PROVISIONS (if applicable)

For patients under 18 years of age:

A. Parental/Guardian Authorization:
I affirm that I am the parent or legal guardian of the minor patient named above and have legal authority to make healthcare decisions for this minor patient.

B. Special Provisions for Minor Consent Services:
I understand that in certain circumstances, minors may consent to their own healthcare services without parental consent as permitted by state law (such as reproductive health services, mental health services, substance use disorder treatment, or sexually transmitted infection testing/treatment). In such cases, the minor's authorization may be required for the release of those specific records.

XV. SIGNATURES

By signing below, I acknowledge that I have read and understand this authorization, and I authorize the use and/or disclosure of my protected health information as described in this document.

Patient Signature: _____________________________________
Date: //______
Time: : □ AM □ PM

OR

Personal Representative Signature: _______________________
Date: //______
Time: : □ AM □ PM

XVI. WITNESS (if required by facility policy)

Witness Signature: ____________________________________
Witness Name (printed): _______________________________
Date: //______

XVII. INTERPRETER (if applicable)

Interpreter Signature: _________________________________
Interpreter Name (printed): ____________________________
Language Interpreted: ________________________________
Date: //______

---

FOR HEALTHCARE PROVIDER USE ONLY

Authorization Received by: ____________________________
Verification Method: _________________________________
Date Processed: //______
Medical Record Updated: □ Yes □ No
Authorization Scanned into Record: □ Yes □ No
Patient/Representative Provided Copy: □ Yes □ No