Authorization For Release Of Protected Health Information Phi Template for United States

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Authorization For Release Of Protected Health Information Phi

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

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What is a Authorization For Release Of Protected Health Information Phi?

The Authorization For Release Of Protected Health Information (PHI) is a crucial document required under U.S. federal HIPAA regulations whenever protected health information needs to be shared with parties other than for direct treatment, payment, or healthcare operations. This document ensures patient privacy rights are protected while facilitating necessary information sharing. It must include specific elements required by federal law, such as a description of the information to be shared, authorized parties, expiration date, and the patient's right to revoke. The authorization may be subject to both federal HIPAA requirements and additional state-specific privacy regulations.

What sections should be included in a Authorization For Release Of Protected Health Information Phi?

1. Patient Information: Full name, date of birth, address, and other identifying information of the patient

2. Healthcare Provider Information: Details of the entity authorized to release the information

3. Recipient Information: Details of the person or entity authorized to receive the information

4. Information to be Released: Specific description of the health information to be disclosed

5. Purpose of Disclosure: Reason for releasing the information

6. Expiration: Date or event upon which the authorization expires

7. Rights and Notifications: Statement of right to revoke and other required HIPAA notifications

8. Signatures: Patient or legal representative signature and date

What sections are optional to include in a Authorization For Release Of Protected Health Information Phi?

1. Special Categories of Records: Additional authorizations for sensitive information such as HIV, mental health, or substance abuse records

2. Electronic Delivery Authorization: Specific authorization for electronic transmission of records

3. Legal Representative Authority: Documentation of authority to act on patient's behalf when someone other than the patient is authorizing release

What schedules should be included in a Authorization For Release Of Protected Health Information Phi?

1. Proof of Identity: Copies of identification documents for verification purposes

2. Legal Documentation: Power of attorney or other legal documents establishing authority to act for patient

3. Specific Records List: Detailed inventory of specific records to be released when extensive or complex

Authors

Alex Denne

Head of Growth (Open Source Law) @ ��Ƶ | 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

Business Associate

Clauses

Relevant Industries

Healthcare
Insurance
Legal Services
Research Institutions

Relevant Teams

Medical Records
Compliance
Legal
Privacy Office
Patient Services

Relevant Roles

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

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What is a Authorization For Release Of Protected Health Information Phi?

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What sections are optional to include in a Authorization For Release Of Protected Health Information Phi?

What schedules should be included in a Authorization For Release Of Protected Health Information Phi?

Authors

Alex Denne

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