FFF HIPAA and Authorization to Release Information

Authorization to Release Health Care Records

Please read this entire form before signing and complete all the sections that apply to your decisions relating to the disclosure of protected health information.

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Birth Date*

MonthDayYear

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

I AUTHORIZE THE RELEASE OF MY PROTECTED HEALTH INFORMATION TO FISHING FOR THE FIGHT FOR THE PURPOSE OF DETERMINING FINANCIAL ASSISTANCE.

I UNDERSTAND THAT FISHING FOR THE FIGHT WILL KEEP MY INFORMATION CONFIDENTIAL AND WITHIN THE FISHING FOR THE FIGHT ORGANIZATION, UNLESS OTHERWISE AGREED UPON BY BOTH PARTIES.

IAUTHORIZE FISHING FOR THE FIGHT TO DISCLOSE THE INDIVIDUAL PATIENT REFERENCED ABOVE'S PROTECTED HEALTH INFORMATION TO MEMBERS OF THE FISHING FOR THE FIGHT ORGANIZATION.

REASON FOR DISCLOSURE (Choose only one option below)*

WHAT INFORMATION CAN BE DISCLOSED? Complete the following by indicating those items that you want disclosed. The signature of a minor patient is required for the release of some of these items. If all health information is to be released, then check only the first box.*

Your initials are REQUIRED to release the following information. (Place initials in boxes below as applicable.

Mental Health Records (excluding psychotherapy notes)

Drug, Alcohol, or Substance Abuse Records

Genetic Information (including Genetic Test Results)

HIV/AIDS Test Results/Treatment

EFFECTIVE TIME PERIOD. This authorization is valid until the earlier of the occurrence of the death of the individual; the individual reaching the age of majority; or permission is withdrawn; or 48 months from the date of execution for existing health information and 12 months for health information created after the effective date of this authorization.

RIGHT TO REVOKE: I understand that I can withdraw my permission at any time by giving written notice stating my intent to revoke this authorization to the person or organization named under "WHO CAN RECEIVE AND USE THE HEALTH INFORMATION."

I understand that prior actions taken in reliance on this authorization by entities that had permission to access my health information will not be affected.

SIGNATURE AUTHORIZATION: I have read this form and agree to the uses and disclosures of the information as described. I understand that refusing to sign this form does not stop disclosure of health information that has occurred prior to revocation or that is otherwise permitted by law without my specific authorization or permission, including disclosures required or permitted under Wyoming Law and/or 45 C.F.R. § 164.502(a1

I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state privacy laws.

Right to name a person that may receive my PHI from Fishing for the Fight

I (patient) authorize the following individual to contact, work with, and supply my PHI to FISHING FOR THE FIGHT on my behalf, and to receive information from FISHING FOR THE FIGHT related to my PHI.

Name of Person Authorized to Receive and Supply Information:

First NameLast Name

Relationship of Person to Individual (Patient)

SpouseParent/Legal GuardianMedical Power of AttorneyOther

Signature of Individual or Individual’s Legally Authorized Representative if the individual is a minor or otherwise incapacitated.*

Printed Name of Legally Authorized Representative (if applicable)

If representative, specify legal relationship to the individual

A minor individual's signature may be required for the release of certain types of information, including for example, the release of information related to certain types of reproductive care, sexually transmitted diseases, and drug, alcohol or substance abuse, and mental health treatment:

Minor Signature as applicable

IMPORTANT INFORMATION ABOUT THE AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION

This form is intended for use in complying with the requirements of the Health Insurance Portability and Accountability Act and Privacy Standards (HIPAA) and Wyoming medical privacy laws.

Health Information to be Released - If "All Health Information" is selected for release, health information includes, but is not limited to, all records and other information regarding health history, treatment, hospitalization, tests, and outpatient care, and also educational records that may contain

As indicated on the form, specific authorization is required for the release of information about certain sensitive conditions, including: Mental health records (excluding "psychotherapy notes" as defined in HIPAA at 45 CFR 164.501Drug, alcohol, or substance abuse records. Records or tests relating to HIV/AIDS. Genetic (inherited) diseases or tests (except as may be prohibited by 45 C.F.R. § 164.502

Note on Release of Health Records - This form is not required for the permissible disclosure of an individual's protected health information to the individual or the individual's legally authorized representative. (45 C.F.R. §§ 164.502(a1i

If a healthcare provider is specified in the "Who Can Receive and Use The Health Information" section of this form, then permission to receive protected health information also includes physicians, other health care providers (such as nurses and medical staff) who are involved in the individual's medical care at that entity's facility or that person's office, and health care providers who are covering or on call for the specified person or organization, and staff members or agents (such as business associates or qualified services organizations) who carry out activities and purposes permitted by law for that specified covered entity or person. If a covered entity other than a healthcare provider is specified, then permission to receive protected health information also includes that organization's staff or agents and subcontractors who carry out activities and purposes permitted by this form for that organization.

Right to Receive Copy - The individual and/or the individual's legally authorized representative has a right to receive a copy of this authorization.