The buttons on this page each connect to the declaration of consent indicated in the overview above. You can receive these documents in any of the formats shown below the image. The following statement in bold (“The purpose of this authorization is”) is followed by a list of instructions (each with a check box). Check the box that applies to the catalyst or the reason you want to share the patient`s medical records. (Numbers 7, 8 and 9 are included in the text of our standard form) The Data Protection Regulation allows, but does not require, that a covered entity voluntarily obtain patient consent for the use and disclosure of protected health information for processing, payment and healthcare. Covered entities that do so have the discretion to design a process that best meets their needs. In contrast, an “authorization” under the Privacy Rule is required for the use and disclosure of protected health information that is not otherwise authorized by the Rule. While the privacy rule requires patient authorization, voluntary consent is not sufficient to permit the use or disclosure of protected health information unless it also meets the requirements of valid authorization. An authorization is a detailed document that gives relevant companies permission to use protected health information for specific purposes that are typically not processing, payment, or healthcare, or to share protected health information with a third party specified by the individual. An authorisation must contain a number of elements, including a description of the protected health information to be used and disclosed, the person authorised to use or disclose, the person to whom the entity concerned may make the disclosure, an expiry date and, in some cases, the purpose for which the information may be used or disclosed.
With a few exceptions, covered entities cannot make the treatment or coverage dependent on the person granting an authorisation. 4 – Indicate the type of information your substitute decision-maker can receive, use and share A person, such as a substitute decision-maker (or “substitute decision-maker”) mentioned in a medical power of attorney (also called an “advance directive”), usually has the authority to obtain medical records. In addition, any person appointed by a court as a guardian or guardian must attach the judgment, order, or executive order to the HIPAA authorization form. Parental consent for abortion of a minor – To be used in states that require parental or guardian consent for a person under the age of eighteen (18) to obtain an abortion. If you require assistance filling out the form, please contact our office at 814-949-5540. An adult or guardian is authorized by federal law to receive a minor`s medical records. If the medical records are intended for the health services provided, the minor may be asked to consent to such treatment on the basis of state law. The medical facility has 30 days to publish the requested medical records. If the original 30-day deadline is not met, they can only extend an additional 30 days if they send a letter to the applicant indicating why the transfer is delayed. Only one (1) renewal period is permitted by law.
A copy of your confidential medical records may be provided to your insurance company or sent to an employer, other university or continuing education provider after signing an information form available at the health and wellness centre. A copy of your medical record will be provided to you within 5 business days of receiving the disclosure of the information. You can select a copy of the consent form for sharing at the health and wellness centre. If you want patient records to be shared at the patient`s request, select the first check box. If there is a specific catalyst that opens the patient`s records, check the second box (“Other”) and describe this reason in the blank space provided. If the disclosing party must be able to contact the patient for marketing purposes, check the third box. If the disclosing party must be able to disclose the patient`s health data to third parties for payment, check the last box on this list. Next, the patient must determine and report when the disclosing party`s right to share their medical records should end. If the patient wants this authorization to end on a specific date, check the first box and enter this calendar date on the blank line that appears after the words “The (date)”.
The patient can also set a specific event to terminate access to the patient`s medical records by checking the second box and placing the catalyst event on the blank line after the words “. The following event occurs. In the section “III. Additional consent for certain conditions”, the patient has the possibility to definitively consent or object to the publication of medical records containing information on physical or sexual abuse, drug abuse, alcoholism, sexually transmitted diseases, abortions or mental treatments. If the patient consents to the disclosing party providing this information, check the first box. If not, select the second check box to specify that this information should be kept private. The patient or their authorized representative must sign the blank line under these options to prove their statement in this matter. Under the signature, he must enter the calendar date and the current time of the day on which he signed this section of the template. Find the last section “IV. Additional consent for HIV/AIDS”, then check the first box if the patient authorizes the disclosure of HIV and/or AIDS medical records, or check the second box to indicate that the patient wishes to prohibit such disclosures.
The “Signature of patient or authorized representative” line must be signed by the patient or a patient representative. In addition, the date and time of the signature must be indicated on the white lines “Date” and “Time”. The Health Record Information Release (HIPAA), also known as the Health Insurance Portability and Accountability Act, is included in each person`s medical record. This document allows a patient to list the names of family members, friends, clergy, health care providers or other third parties (3.) to whom they would like their medical information to be provided. If someone were to request medical information about a particular patient and their name is not on the HIPAA form, they would not be legally aware of the patient`s information. The document also provides an opportunity for health care providers to share information with each other. This document may be revoked and/or reassigned at any time at the discretion of the patient. Power of Attorney for Minors (Child) – Also known as a “consent form” that empowers a family member, friend or guardian to take responsibility for educational, medical and day-to-day decisions. If the patient wishes to have all of their medical information shared by the disclosing party above, check the first box. If the patient wants only information relating to a particular topic to be disclosed by the disclosing party, check the second box and specify the type of information that appears in the blank line after the words “. in relation to the treatment or condition.
If the patient wants only medical records created for their healthcare over a period of time to be shared, select the third check box. Of course, you need to specify a start date for this period and an end date. Use the two blank lines to save this data in this order. If you want the disclosing party to use the patient`s medical records only for criteria other than the options above, check the fourth box and then use the blank line labeled “Other” to provide a full description of what the agent can and cannot access. Find the statement in bold that begins with the sentence “The above part may disclose. Starts. Then provide the legal name of the entity with which the patient shared their medical record. In addition to the name of this entity, you must enter “Address”, “City”, “State”, “Postal Code”, “Telephone”, “Fax” and “Email” in the blank lines marked appropriately. If other entities are to be listed here, you can use the software you use to enter information to insert more rows just below this box. If you complete this form by hand, be sure to cite a properly titled (dated and signed) attachment that includes who is authorized to receive the patient`s medical information. 2 – Create the patient information requested in the introduction Now that we have named the entity that requires patient consent, we need to define what information the patient is happy to share.
A short list of checkbox instructions has been added to facilitate this definition.
