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Phi Consent Form
1. Patient Information: Basic identifying information of the patient including name, date of birth, contact details, and medical record number
2. Purpose of Consent: Clear explanation of why PHI is being collected, how it will be used, and who will have access to it
3. Information to be Disclosed: Specific description of what Protected Health Information will be shared, including types of records and date ranges
4. Duration: Time period for which the consent is valid, including start date and expiration date
5. Rights Statement: Detailed explanation of patient's rights regarding their PHI, including right to revoke consent and right to receive copies
6. Authorization Statement: Formal statement confirming understanding and voluntary nature of consent
7. Signatures: Signature blocks for patient/legal representative, date, and witness if required
1. Research Purposes: Additional provisions for research use of PHI, including study details and potential risks
2. Special Categories of Information: Specific consent sections for sensitive information such as HIV/AIDS, mental health, substance abuse, or genetic information
3. Electronic Communication Consent: Additional consent for sharing PHI through electronic means, including email or patient portals
4. Third Party Recipients: Detailed list of other entities or individuals who may receive the PHI beyond the primary healthcare provider
5. Payment Information: Sections related to billing and insurance when PHI sharing involves payment processing
1. Notice of Privacy Practices: Detailed explanation of privacy policies and procedures as required by HIPAA
2. Revocation Form: Standard form for withdrawing consent with instructions for submission
3. State-Specific Addendum: Additional requirements and disclosures based on applicable state laws
4. List of Covered Entities: Comprehensive list of healthcare providers, facilities, and other entities covered by the consent
Authors
Covered Entity
Authorization
Disclosure
Health Care Provider
Treatment
Use
Business Associate
Notice of Privacy Practices
Electronic Health Record (EHR)
Minimum Necessary
Personal Representative
Revocation
Health Care Operations
Payment
Research
De-identified Information
Individual
Third Party Recipients
Expiration Date
Information Use and Disclosure
Duration and Expiration
Revocation Rights
Privacy Rights
Re-disclosure
Information Security
Record Access
Data Sharing
Confidentiality
Patient Rights
Purpose Limitation
Minimum Necessary Disclosure
Special Categories of Information
Electronic Records
Third Party Access
Research Use
Payment and Operations
State-Specific Requirements
Liability and Indemnification
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Genie is the safest place to draft. Here’s how we prioritise your privacy and security.
Your documents are private:
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Our bank-grade security infrastructure undergoes regular external audits
We are ISO27001 certified, so your data is secure
Organizational security
You retain IP ownership of your documents
You have full control over your data and who gets to see it
Innovation in privacy:
Genie partnered with the Computational Privacy Department at Imperial College London
Together, we ran a £1 million research project on privacy and anonymity in legal contracts
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