Consent Form To Release Medical Information To A Third Party

Consent Form To Release Medical Information To A Third Party Template for United States

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Key Requirements PROMPT example:

"I need a Consent Form To Release Medical Information To A Third Party for my elderly mother's medical records to be shared with both her new primary care physician and her insurance company, with the authorization lasting until March 2025."

Document background

The Consent Form To Release Medical Information To A Third Party is essential in healthcare settings where patient information needs to be shared while maintaining compliance with HIPAA and state privacy laws. This document becomes necessary when medical records need to be shared with parties other than the primary healthcare provider, such as specialists, insurance companies, or legal representatives. The form must specify exactly what information can be shared, with whom, for what purpose, and for how long. It serves as a protective measure for both healthcare providers and patients, ensuring that private medical information is only shared with explicit authorization.

Suggested Sections

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

2. Healthcare Provider Information: Name and contact information of the entity releasing the information

3. Recipient Information: Name and contact information of the person/entity receiving the information

4. Information to be Released: Specific description of what medical information is to be shared, including date ranges

5. Purpose of Release: Reason for releasing the medical information

6. Duration: Expiration date or event for the authorization

7. Rights Statement: Statement of right to revoke and how to do so, plus acknowledgment that treatment cannot be conditioned on signing

Optional Sections

1. Specific Authorizations: Additional permissions for sensitive information including mental health records, HIV status, genetic information, and substance abuse treatment records

2. Electronic Delivery Authorization: Permission and preferences for transmitting records electronically, including associated risks

3. Payment Authorization: Authorization for any fees associated with records release and copying

Suggested Schedules

1. List of Specific Records: Detailed itemization of specific records to be released when the release is for select documents only

2. State-Specific Addendum: Additional provisions and notices required by specific state laws

3. HIPAA Notice: Standard HIPAA privacy notice explaining how medical information may be used and disclosed

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
Education

Relevant Teams

Medical Records
Compliance
Legal
Administration
Privacy Office

Relevant Roles

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

Industries

HIPAA: Health Insurance Portability and Accountability Act of 1996 - Primary federal law governing medical privacy and security requirements for protected health information

HITECH Act: Health Information Technology for Economic and Clinical Health Act - Strengthens HIPAA privacy and security protections and enforcement

42 CFR Part 2: Federal regulations specifically governing confidentiality of substance abuse treatment records, with stricter requirements than HIPAA

ADA: Americans with Disabilities Act - Ensures medical information related to disabilities is properly protected and handled

State Privacy Laws: Individual state laws that may impose additional or more stringent requirements than federal regulations for medical information privacy

State Record Retention Laws: State-specific requirements for how long medical records must be maintained and preserved

State Mental Health Laws: State-specific regulations governing the handling and release of mental health records, often with additional protections

Sensitive Health Information Laws: State-specific laws regarding special categories of health information such as HIV/AIDS status, requiring additional protections or specific consent procedures

Patient Identification Requirements: Legal requirements for properly identifying patients in medical release forms, including necessary demographic information

Information Specificity Requirement: Legal requirement that the consent form must specifically describe what information is being released

Purpose Specification Requirement: Legal requirement that the consent form must clearly state the purpose for which the information is being released

Expiration Requirement: Legal requirement that the consent form must include an expiration date or event

Revocation Rights: Legal requirement to inform patients of their right to revoke authorization and how to do so

Redisclosure Statement: Required statement informing patients about potential redisclosure of their information by the receiving party

Treatment Non-Conditioning Statement: Required statement that treatment cannot be conditioned on signing the release form

Minor Consent Requirements: Special legal requirements for obtaining consent for release of minors' medical information

Genetic Information Provisions: Special provisions for handling and releasing genetic information, which may have additional protections

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Authors

Alex Denne

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