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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.

This form is used to release your protected health information as required by federal and state privacy laws. 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.

The term unauthorized means the inappropriate access, review, or viewing of patient medical informa- tion without a direct need for medical diagnosis, treatment, or other lawful use.

The core elements of a valid authorization include: A meaningful description of the information to be disclosed. The name of the individual or the name of the person authorized to make the requested disclosure. The name or other identification of the recipient of the information.

A HIPAA patient authorization form is an agreement between a patient and healthcare provider. A signed form gives your organization permission to use the patient's health information or disclose it to another person or entity, depending on their wishes.

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.

What Must be Included on a HIPAA Medical Release Form? A description of the PHI that may be shared or disclosed. The purpose for the PHI disclosure. The name of the entity or person(s) with whom the PHI will be shared. A date by which the authorization for the disclosure will expire.

A signature and date that the authorization is signed by an individual or an individual's representative. If a representative is signing the form, the relationship with the patient must be detailed along with a description of the representative's authority to act on behalf of the patient.

An authorization must specify a number of elements, including a description of the protected health information to be used and disclosed, the person authorized to make the use or disclosure, the person to whom the covered entity may make the disclosure, an expiration date, and, in some cases, the purpose for which the

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A Discharge Summary can often be given to you at the time you fill out an authorization. • Please bring an official ID if you are picking up your records.Complete the TUP Request to Release Medical Information form. As soon as we can complete your request, it will be provided or sent. You'll probably need to fill out a form. Treatment Locators Find treatment facilities and programs in the United States or U.S. Territories for mental and substance use disorders. Police Department; Media Releases CLEARWATER, Fla. Get FREE email alerts for this search!

Philadelphia Pennsylvania Authorization to Release Confidential Records

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