HIPAA Privacy Rule

HIPAA Privacy Rule of Patient Authorization Agreement

Authorization for the Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.508(a))

As part of my healthcare, I understand that this Practice originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment, and any plans for future care or treatment. I understand that this information serves as:

A basis for planning my care and treatment.
a means of communication among the health professionals who may contribute to my health care;
a source of information for applying my diagnosis and surgical information to my bill;
a means by which a third-party payer can verify that services billed were provided;
A tool for routine health care operations such as assessing quality and reviewing the competence of health care professionals.

I have received a copy of the Notice of Privacy Practices that provides a more complete description of information uses and disclosures.

I understand that as part of my care and treatment, I may need to provide my Protected Health Information to another covered entity. I have the right to review this Practice’s notice before signing this authorization. I authorize the disclosure of my Protected Health Information as specified below for my purposes and to the parties I have designated.

Privacy Rule of Patient Consent Agreement

Consent to the Use and Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.506(a))

Unless required by law, disclosure of your PHI in the situations below and any others not described in this notice will be made only with your consent, written authorization, or the opportunity to object. You may revoke your authorization in writing at any time, except that your physician or the physician’s practice has acted in reliance on the use or disclosure indicated in the approval.

Communication with family and individuals. Unless you object, your PHI may be disclosed to a family member, friend, or other individual whom you have identified and who is involved in your care or payment for your care.
We may disclose your PHI to disaster relief organizations and notify family members or friends of your location and condition.
Psychotherapy Notes. We will only disclose psychotherapy notes with your written authorization in circumstances other than law-appropriate ones.
Disclosures for marketing purposes or the sale of your PHI require your written authorization.

I understand that:

I have the right to review the Practice’s Notice of Information practices before signing this consent form.
This Practice reserves the right to change the notice and practices. Before implementation, I will mail a copy of any notice to the address I’ve provided if requested.
I have the right to object to using my health information for directory purposes.
I have the right to request restrictions on how my Protected Health Information may be used or disclosed to carry out treatment, payment, or healthcare operations, and this Practice is not required by law to agree to the restrictions requested.
I may revoke this consent in writing at any time, except that this Practice has already acted in reliance thereon.

“I acknowledge receiving and reading the Notice of Health Information Practices. My healthcare provider participates in Health Current, Arizona’s health information exchange (HIE). I understand that my health information may be securely shared through the HIE unless I complete and return an Opt-Out Form to my healthcare provider.”

HIPAA Privacy Rule