authorization for use or disclosure

         of protected health information                                       

1. Client's Name:  ________________________________________________________________

2. Date of Birth: ___/___/___

 

3. Date authorization initiated: ___/___/___

 

4. Authorization initiated by:

 

______________________________________________________________________

Name (client, provider, or other)

 

5. Information to be released:

    Authorization for Psychotherapy Notes ONLY (Important: If this authorization is for

    Psychotherapy Notes, you must not use it as an authorization for any other type of

    protected health information.)

 

    Other (describe information in detail):

 

_______________________________________________________________________________________________________________

 

6. Purpose of Disclosure: The reason I am authorizing release is:_______________________________________________

 

________________________________________________________________________________________________________________

My request:____________________________________________________________________________________________________

________________________________________________________________________________________________________________

 

7. Person(s) Authorized to Make the Disclosure:

________________________________________________________________________________________________________________

 

8. Person(s) Authorized to Receive the Disclosure:

________________________________________________________________________________________________________________

 

9. This Authorization will expire on ___/___/___ or upon the happening of the following event:

_______________________________________________________________________________________________________________

 

Authorization and Signature: I authorize the release of my confidential protected health

information, as described in my directions above. I understand that this authorization is voluntary,

that the information to be disclosed is protected by law, and the use/disclosure is to be made to

conform to my directions. The information that is used and/or disclosed pursuant to this

authorization may be re-disclosed by the recipient unless the recipient is covered by state laws

that limit the use and/or disclosure of my confidential protected health information.

 

Signature of the Patient (or Signature of Personal Representative):

 

_________________________________________________________________

 

Relationship to Patient of Personal Representative:

 

___________________________________________Date of signature: _____________________

 

 

 

 

 patient rights and hippa authorizations

 

 

The following specifies your rights about this authorization under the Health Insurance Portability

and Accountability Act of 1996, as amended from time to time (“HIPAA”).

 

1.     Tell your mental health professional if you don’t understand this authorization, and they will

        explain it to you.

 

2.     You have the right to revoke or cancel this authorization at any time, except: (a) to the

        extent information has already been shared based on this authorization; or (b) this 

        authorization

        was obtained as a condition of obtaining insurance coverage. To revoke or cancel this

        authorization, you must submit your request in writing to your mental health professional and

        your insurance company, if applicable.

 

3.     You may refuse to sign this authorization. Your refusal to sign will not affect your ability to

        obtain treatment, make payment, or affect your eligibility for benefits. If you refuse to sign this

        authorization, and you are in a research-related treatment program, or have authorized your

        provider to disclose information about you to a third party, your provider has the right to decide

        not to treat you or accept you as a client in their practice.

 

4.     Once the information about you leaves this office according to the terms of this

        authorization, this office has no control over how it will be used by the recipient. You need to be

        aware that at that point your information may no longer be protected by HIPAA.

 

5.     If this office initiated this authorization, you must receive a copy of the signed authorization.

 

6.     Special Instructions for completing this authorization for the use and disclosure of

        Psychotherapy Notes. HIPAA provides special protections to certain medical records known as

        “Psychotherapy Notes.” All Psychotherapy Notes recorded on any medium (i.e., paper,  

        electronic) by a mental health professional (such as a psychologist or psychiatrist) must be kept     

        by the author and filed separate from the rest of the client’s medical records to maintain a 

        higher standard of protection. “Psychotherapy Notes” are defined under HIPAA as notes

        recorded by a health care provider who is a mental health professional documenting or 

        analyzing the contents of conversation during a private counseling session or a group, joint, or

        family counseling session and that are separate from the rest of the individual’s medical 

        records. Excluded from the “Psychotherapy Notes” definition are the following: (a) medication

        prescription and monitoring, (b) counseling session start and stop times, (c) the modalities and

        frequencies of treatment furnished, (d) the results of clinical tests, and (e) any summary of: 

        diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.

 

        In order for a medical provider to release “Psychotherapy Notes” to a third party, the client who

        is the subject of the Psychotherapy Notes must sign this authorization to specifically allow for 

        the release of Psychotherapy Notes. Such authorization must be separate from an 

        authorization to release other medical records.

 

 

Signature of the Patient (or Signature of Personal Representative):

 

 

_________________________________________________________________

 

Relationship to Patient of Personal Representative:

 

 

___________________________________________Date of signature: _____________________

 

 

 

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