Consent For Use And Disclosure Of Health Information Form

Consent For Use And Disclosure Of Health Information Form Template for United States

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Key Requirements PROMPT example:

"I need a Consent For Use And Disclosure Of Health Information Form for my medical research facility that specifically covers sharing patient data with our partner universities in Europe, with extra provisions for handling genetic information and a validity period until December 2025."

Document background

The Consent For Use And Disclosure Of Health Information Form is a critical document required under U.S. healthcare privacy laws, particularly HIPAA. It serves as a formal authorization mechanism enabling healthcare providers to legally share protected health information while maintaining patient privacy rights. This document becomes necessary whenever protected health information needs to be shared beyond what is permitted by HIPAA's standard allowances for treatment, payment, and healthcare operations. It must specify the information being shared, intended recipients, purpose, and duration of the authorization, while informing patients of their right to revoke consent.

Suggested Sections

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

2. Provider Information: Details of the healthcare provider/organization requesting consent, including name, address, and contact information

3. Scope of Consent: Specific information being authorized for disclosure, including types of medical records and time periods covered

4. Purpose of Disclosure: Detailed explanation of why the health information is being shared and who may receive it

5. Duration: Time period for which the consent remains valid and expiration date of the authorization

6. Rights Statement: Comprehensive explanation of patient's rights regarding revoking consent, restrictions, and right to refuse to sign

7. Signature Block: Space for patient/authorized representative signature, date, and relationship to patient if not self

Optional Sections

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

2. Electronic Disclosure Authorization: Specific consent for electronic transmission of health information, including acknowledgment of potential security risks

3. Research Authorization: Specific consent for use of health information in research purposes, including scope and duration of research use

Suggested Schedules

1. Notice of Privacy Practices: Detailed explanation of how health information may be used and disclosed, and patient privacy rights under HIPAA

2. State-Specific Addendum: Additional provisions and requirements specific to state laws regarding health information privacy

3. Revocation Form: Standard form for patient to withdraw consent in the future, including instructions for submission

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
Research Institutions
Pharmaceutical

Relevant Teams

Legal
Compliance
Medical Records
Information Technology
Human Resources

Relevant Roles

Privacy Officer
Medical Records Manager
Healthcare Administrator
Compliance Officer
Medical Director

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