Taos Clinic for Children & Youth

Taos Clinic for Children & Youth

Taos Clinic For Children & Youth

123 Cruz Alta Road, Taos, NM 87571

Tel: (575) 758-8651

Fax: (575) 758-7811

HIPPA Valid Authorization Letter

To Whom It May Concern:

Your request for medical records from our office has been denied. The authorization forms we received is not HIPPA compliant. We have enclosed one of our authorization forms for your convenience. Please call: (575) 758-8651 if you have any questions.

Your request is missing the following checked conditions:

 Description of information to be used or disclosed that identifies the information in a specific and meaningful fashion.

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

 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.

 A description of each purpose of the requested use or disclosure. The statement “at the request of the individual” is a sufficient description of the purpose when and individual initiates the authorization and does not, or elects not to provide a statement of purpose.

 An expiration date or and expiration events that relates to the individual or the purpose of the use or disclosure.

 Signature of the individual and date. If the authorization is signed by a personal representative of the individual, a description of such representative’s authority to act for the individual must also be provided.

The following checked statements are missing form your authorization:

 The individual’s right to revoke the authorization in writing and the exceptions to the right to revoke and a description of how the individual may revoke the authorization. Example: I understand I have the right to revoke this authorization in writing at any time, my written revocation must be submitted to the privacy officer at P.O. Box XY, Taos, NM 87571. I understand the revocation will not apply to information that has already been released in response to this authorization.

 The ability or inability to condition treatment, payment, enrollment or eligibility for benefits on the authorization. Example: I understand that my treatment, payment, or eligibility for benefits will not be conditioned on whether I provide authorization for the requested us4 or disclosure.

 The potential for the information disclosed to be subject to re-disclosure by the recipient and no longer be protected by federal laws. Example: I understand that information released pursuant to this authorization may be subject to re=-disclosure by the recipient and may no longer be protected by federal law.

 A statement of the right of the patient to examine and copy the information to be disclosed

 A statement forbidding further disclosure of the information without obtaining proper authorization unless such disclosure is required by state / federal law,

 If the patient is 14 years or older, they must sign the authorization in addition to the parent/ guardian