Authorization for Use and / or Disclosure of Protected Health Information
What this document covers
The Authorization for Use and/or Disclosure of Protected Health Information is a legal document that allows employees to authorize the release of their medical information by their organization's human resources department. This form specifically outlines the types of medical information that can be disclosed, distinguishing it from other generic authorization forms by focusing on health-related data. It is crucial for protecting your privacy while ensuring necessary medical information can be shared when needed.
Form components explained
- Authorization section specifying the person(s) or organization permitted to disclose the health information.
- Details regarding the types of medical information that may be disclosed.
- Acknowledgment that you can inspect or copy the information disclosed under this authorization.
- Statement confirming your right to receive a copy of the signed authorization.
When this form is needed
This form is needed when you want to give consent for your employerâs human resources department to access and share specific medical information. It is commonly used for purposes such as requesting reasonable accommodations or when applying for benefits related to health conditions.
Who should use this form
- Employees who need to authorize their employer to disclose health information.
- Individuals seeking accommodations in the workplace based on health issues.
- Employees applying for health-related benefits that require disclosure of their medical records.
Steps to complete this form
- Enter your name and contact information at the top of the form.
- Identify the person(s) or organization authorized to disclose your health information.
- List the specific types of medical information that you are permitting to be disclosed.
- Sign and date the authorization at the bottom of the form.
- Ensure you receive a copy of the signed form for your records.
Does this document require notarization?
This form does not typically require notarization to be legally valid. However, some jurisdictions or document types may still require it. US Legal Forms provides secure online notarization powered by Notarize, available 24/7 for added convenience.
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Make edits, fill in missing information, and update formatting in US Legal Forms—just like you would in MS Word.
Download a copy, print it, send it by email, or mail it via USPS—whatever works best for your next step.
Sign and collect signatures with our SignNow integration. Send to multiple recipients, set reminders, and more. Go Premium to unlock E-Sign.
If this form requires notarization, complete it online through a secure video call—no need to meet a notary in person or wait for an appointment.
We protect your documents and personal data by following strict security and privacy standards.
Common mistakes
- Failing to specify the types of health information to be disclosed.
- Not signing and dating the authorization before submission.
- Omitting the name of the person or organization authorized to disclose the information.
Advantages of online completion
- Convenient access to legal form templates anytime, allowing for immediate completion.
- Easy customization to tailor the form to your specific needs.
- Reliable legal content drafted by licensed attorneys, ensuring compliance.
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FAQ
Your authorization allows the Health Plan (your health insurance carrier or HMO) to release your protected health information to a person or organization that you choose.Revoking this authorization will not affect any action taken prior to receipt of your written request.
The law requires that a HIPAA authorization form contain specific core elements to be valid. These elements include: A description of the specific information to be used or disclosed. The name or other specific identification of the person(s), or class of persons, authorized to make the requested use or disclosure.
This authorization or release is commonly called a Medical Authorization Release.We do not recommend that you sign anything, especially the Medical Authorization Release, from the insurance company until after you speak with an experienced and knowledgeable personal injury attorney.
Authorized Disclosure means the disclosure of Protected Information strictly in accordance with the Confidentiality Control Procedures applicable thereto: (i) as to all Protected Information, only to a Related Party that has a need to know such Protected Information strictly for Project Purposes and that has agreed in
It is important to emphasize the difference between a use and a disclosure of PHI. In general, the use of PHI means communicating that information within the covered entity.Disclosure - The release, transfer, access to, or divulging of information in any other manner outside the entity holding the information.
No, you should not sign the HIPAA authorization for the release of your medical records. Often, the insurance company will act as though they cannot begin to decide how much money to offer you until they have all of your medical records.
One fact sheet addresses Permitted Uses and Disclosures for Health Care Operations, and clarifies that an entity covered by HIPAA (covered entity), such as a physician or hospital, can disclose identifiable health information (referred to in HIPAA as protected health information or PHI) to another covered entity (or
An authorization is a detailed document that gives covered entities permission to use protected health information for specified purposes, which are generally other than treatment, payment, or health care operations, or to disclose protected health information to a third party specified by the individual.
In general, a covered entity may only use or disclose PHI if either: (1) the HIPAA Privacy Rule specifically permits or requires it; or (2) the individual who is the subject of the information gives authorization in writing. We note that this blog only discusses HIPAA; other federal or state privacy laws may apply.