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Authorization To Disclose Phi for the United States

Authorization To Disclose Phi Template for United States

An Authorization to Disclose PHI is a legal document required under U.S. HIPAA regulations that gives healthcare providers and other covered entities permission to share specific protected health information with designated recipients. This document must comply with federal HIPAA requirements and applicable state privacy laws, containing specific elements such as the type of information to be shared, purpose of disclosure, expiration date, and the patient's right to revoke the authorization.

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Authorization To Disclose Phi

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What is a Authorization To Disclose Phi?

The Authorization To Disclose PHI is a crucial document in U.S. healthcare privacy compliance. Required by HIPAA and state privacy laws, this authorization form serves as the patient's explicit permission for sharing their protected health information. It's necessary whenever protected health information needs to be shared with parties other than for treatment, payment, or healthcare operations. The document must specify what information can be shared, with whom, for what purpose, and for how long. It must also inform patients of their right to revoke the authorization and any potential for redisclosure of the information.

What sections should be included in a Authorization To Disclose Phi?

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

2. Information to be Disclosed: Specific description of the health information authorized for disclosure

3. Purpose of Disclosure: Clear statement of why the information is being disclosed

4. Authorized Recipients: Identity of persons/organizations authorized to receive the information

5. Duration: Expiration date or event for the authorization

6. Rights Statement: Statement of right to revoke and process for revocation

7. Signatures: Patient signature, date, and witness if required

What sections are optional to include in a Authorization To Disclose Phi?

1. Special Categories Authorization: Specific authorization for sensitive information (mental health, HIV, substance abuse)

2. Representative Authorization: Details of authorized representative if not patient

What schedules should be included in a Authorization To Disclose Phi?

1. State-Specific Addendum: Additional provisions required by specific state laws

2. Revocation Form: Form for future revocation of authorization

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

Jurisdiction

United States

Publisher

Ƶ

Cost

Free to use
Clauses




















Industries

HIPAA Privacy Rule: Primary federal regulation governing the use and disclosure of protected health information (PHI), establishing standards for patient privacy rights and authorization requirements

HIPAA Security Rule: Sets national standards for securing electronic protected health information, including technical, physical, and administrative safeguards

HIPAA Enforcement Rule: Establishes procedures for compliance and investigations, along with penalties for violations of HIPAA Privacy and Security Rules

HITECH Act: 2009 legislation that strengthens privacy and security protections for health information and strengthens the enforcement of HIPAA rules

State Privacy Laws: State-specific regulations that may impose additional or stricter requirements for health information privacy and disclosure authorization

42 CFR Part 2: Federal regulations providing additional privacy protections for substance use disorder treatment records

Plain Language Requirement: Authorization must be written in clear, understandable language avoiding complex legal terminology

PHI Description Requirement: Authorization must specifically describe what protected health information will be disclosed

Disclosure Parties Identification: Authorization must clearly identify who is authorized to disclose the information and who will receive it

Expiration Requirement: Authorization must include either an expiration date or expiration event

Revocation Rights: Authorization must include a statement explaining the individual's right to revoke the authorization

Redisclosure Notice: Authorization must include a statement that information may be subject to redisclosure by the recipient

Signature Requirements: Authorization must include the individual's signature and date of signing to be valid

Teams

Employer, Employee, Start Date, Job Title, Department, Location, Probationary Period, Notice Period, Salary, Overtime, Vacation Pay, Statutory Holidays, Benefits, Bonus, Expenses, Working Hours, Rest Breaks,  Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination,  Severance Pay, Governing Law, Entire Agreemen

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