The General Medical Authorization Form serves as a crucial document in the U.S. healthcare system, enabling compliant information sharing while protecting patient privacy rights. This form is required whenever protected health information needs to be shared with parties other than the direct healthcare provider, whether for continued care, insurance purposes, legal proceedings, or other authorized reasons. The document must comply with HIPAA regulations and state-specific requirements, including special provisions for sensitive information such as mental health records, substance abuse treatment, or HIV status. The authorization remains valid for a specified period and can be revoked by the patient at any time.
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1. Patient Information: Full legal name, date of birth, address, contact information
2. Healthcare Provider Information: Name and contact details of the provider/facility authorized to release information
3. Recipient Information: Details of person/entity authorized to receive the medical information
4. Information to be Released: Specific description of medical information authorized for release
5. Purpose of Disclosure: Stated reason for releasing the medical information
6. Duration: Expiration date or event for the authorization
7. Rights Statement: Patient's rights regarding the authorization including right to revoke
1. Special Authorization: Additional authorization for sensitive information (HIV, mental health, substance abuse)
2. Minor Authorization: Parent/guardian authorization details for cases involving minors
3. Re-disclosure Statement: Statement about potential re-disclosure by recipient and associated implications
1. State-Specific Addendum: Additional requirements based on state law
2. Revocation Form: Form to revoke the authorization
3. Instructions Sheet: Detailed instructions for completing the form
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