Model Authorization Form[1]

AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION

Read entire document before signing

Patient Name: ______

Date of Birth: _____/_____/_____

1. I authorize the use or disclosure of the above named individual’s health information described below.[2]

2. The following individual(s) or organization(s) are authorized to make this disclosure: ______

______

3.The information identified below may be disclosed to or used by the following individual(s) or organizations(s):

Name: ______

Address: ______

4.The type of information that may be disclosed is as follows:

 Diagnostic and medication history

 Entire record

 Summary only

 Other (please give specific description) ______

______

5.Specially protected information (Please check all that apply.)

 I understand that the information to be disclosed may include information relating to AIDS or

HIV.

 I understand that the information to be disclosed includes mental health information[3]

 I understand that the information to be disclosed may include information about treatment for

drug, alcohol, or substance abuse.

6.This information for which I am requesting disclosure will be used for the following purpose:

 My medical treatment

 Insurance payment/reimbursement

 My personal use

 To evaluate my eligibility for life insurance coverage

 To evaluate my eligibility for disability benefits

 At the request of my attorney (name ______) for ______

 Other (please describe) ______

7.I understand that I have the following rights:

  • Right not to sign. You may refuse to sign this authorization. Refusal to sign will not affect your ability to obtain treatment by(name of physician/practice releasing information) ______except when health services are solely for the purpose of reporting to a third party.
  • Right to revoke. You may revoke this authorization at any time. Your revocation will not apply to any release already made in response to this authorization. To revoke this authorization, you must submit a written revocation to:

Practice privacy officer or physician’s name: ______

Address:______

  • Re-disclosure. I understand that once the information listed above has been disclosed, it could potentially be re-disclosed because the information may no longer be protected by federal privacy laws or regulations.

8.Expiration date or event: ______

I have read and understand this authorization, and authorize the use and/or disclosure of the health information as described in this authorization.

______

Signature of patient (or parent, legal guardian, or other legally authorized representative)

Name of personal representative (please print) ______

Relationship to patient ______

Date ______

Laws & regs/HIPAA consent form.doc

[1]Disclaimer: The Pennsylvania Psychiatric Society (PPS) has provided this sample authorization form as a service to assist PPS members in complying with federal, HIPAA privacy regulations imposing conditions on the release of medical information and requirements for written consent. The form is based on the specific interplay between HIPAA and Pennsylvania law as applied to a psychiatric practice and records. This form is provided as a guide. PPS believes that it conforms to HIPAA requirements, but it has not been reviewed or endorsed by federal or state authorities. Psychiatrists or others using this form assume full responsibility for their use of the form and agree that the PPS is not liable for any claim, loss, or damage arising from their use or reliance upon it.

[2] Both HIPAA and Pennsylvania law contain certain limited exceptions to the general concept that patients control access to the release of their records, in whole or in part, including release to themselves. E.g., exceptions exist for information received under the expectation of privacy, or for information whose release would be detrimental to the patient’s health or dangerous to others. Psychiatrists who are unsure of the requirements in a particular situation should consult with an attorney.

[3]Under HIPAA, “psychotherapy notes” are subject to special rules and cannot be released without the patient’s express permission. IMPORTANT: A SEPARATE RELEASE MUST BE USED FOR PSYCHOTHERAPY NOTES AS DEFINED UNDER HIPAA. To qualify for special protection as “psychotherapy notes,” the material subject to the restriction must be kept separate from other material in the medical record. Basic information such as medication records, counseling session start and stop times, the types and frequencies of treatment received, test results, diagnosis, condition, treatment plan, symptoms, prognosis, or treatment progress are not considered “psychotherapy notes.” Under HIPAA, physicians are not required to provide patients with copies of the psychotherapy notes, even if the patient requests the notes.