Authorization For Disclosure Of Protected Health Information Form Template for United States

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Key Requirements PROMPT example:

Authorization For Disclosure Of Protected Health Information Form

"I need an Authorization For Disclosure Of Protected Health Information Form that allows my primary care physician to share my complete medical history from the past five years with a specialist, specifically including mental health records, with the authorization expiring on March 15, 2025."

Document background

The Authorization For Disclosure Of Protected Health Information Form is required under U.S. federal HIPAA regulations whenever protected health information needs to be shared with third parties outside of treatment, payment, or healthcare operations. This document ensures patient privacy rights while facilitating necessary information sharing. It must include specific elements required by federal law, such as a description of the information to be shared, recipient details, expiration date, and patient's right to revoke. The form is particularly important in situations involving insurance claims, legal proceedings, or continuity of care between different healthcare providers.

Suggested Sections

1. Patient Information: Basic identifying information about the patient including name, date of birth, address, and contact details

2. Information to be Disclosed: Specific description of the health information authorized for disclosure, including type and date range of records

3. Purpose of Disclosure: Statement of the specific reason(s) for releasing the information

4. Authorization Period: Specification of when the authorization becomes invalid, including expiration date or event

5. Recipient Information: Details of person or entity authorized to receive the information, including name, address, and relationship to patient

6. Rights Statement: Comprehensive statement of patient's rights regarding the authorization, including right to revoke and notice about redisclosure

7. Signatures: Signature section for patient or legal representative, including date and time of signing

Optional Sections

1. Special Categories Authorization: Additional specific authorization for sensitive information such as HIV/AIDS status, mental health records, genetic information, or substance abuse treatment records

2. Legal Representative Information: Section for documenting details of person signing on patient's behalf, including their authority to act for the patient

3. Minor Patient Provisions: Special provisions and requirements when the patient is a minor, including parental/guardian consent requirements

Suggested Schedules

1. Identity Verification Documents: Schedule for attaching copies of identification documents or other materials verifying the identity of the requester

2. Legal Authority Documentation: Schedule for attaching documentation proving legal authority when form is signed by a representative (e.g., power of attorney, court order)

3. Specific Records Checklist: Detailed checklist of specific types of records being requested for disclosure

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

Relevant legal definitions

Clauses

Relevant Industries

Healthcare
Insurance
Legal Services
Research Institutions

Relevant Teams

Medical Records
Compliance
Legal
Administration
Patient Services

Relevant Roles

Medical Records Administrator
Privacy Officer
Healthcare Administrator
Compliance Manager
Medical Office Manager

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Let's create your Authorization For Disclosure Of Protected Health Information Form

Authors

Alex Denne

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