This form is for use and/or disclosure of the specific personally identifiable health information identified in form, specifically Psychotherapy Notes, pursuant to the requirements of 45 C.F.R. Sect 164.508, which sets out the federal privacy regulations for the Health Insurance Portability and Accountability Act of 1996 and authorizes the Covered Entity identified in the form to release the personally identifiable health information specifically referenced in th form.
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A covered entity must disclose protected health information in only two situations: (a) to individuals (or their personal representatives) specifically when they request access to, or an accounting of disclosures of, their protected health information; and (b) to HHS when it is undertaking a compliance investigation or ...
Elements: A description of the PHI. The name of the person making the authorization. The name of the person or organization who is authorized to receive the PHI. A description of the purpose for the use or disclosure. An expiration date for the authorization. The signature of the person making the authorization.
Examples of disclosures that would require an individual's authorization include disclosures to a life insurer for coverage purposes, disclosures to an employer of the results of a pre-employment physical or lab test, or disclosures to a pharmaceutical firm for their own marketing purposes.
§ 164.508?. With few exceptions, the Privacy Rule requires a covered entity to obtain individual authorization prior to a disclosure of psychotherapy notes, even for a disclosure to a health care provider other than the originator of the notes, for treatment purposes.
All authorization forms used by a patient permitting uses and disclosures of PHI must be in plain language, and contain specific information regarding the information to be disclosed or used, the person(s) disclosing and receiving the information, the expiration date of the authorization, and the right to revoke the ...
Authorization Core Elements: A description of the PHI to be used or disclosed, identifying the information in a specific and meaningful manner. The names or other specific identification of the person or persons (or class of persons) authorized to make the requested use or disclosure.
The Department adopts in paragraph (c)(1), the following core elements for a valid authorization: (1) a description of the information to be used or disclosed, (2) the identification of the persons or class of persons authorized to make the use or disclosure of the protected health information, (3) the identification ...
All authorizations must be in plain language, and contain specific information regarding the information to be disclosed or used, the person(s) disclosing and receiving the information, expiration, right to revoke in writing, and other data.
