Hipaa Records Release - Greenwich Pediatrics (Page 3 of 3) in pdf

PLEASE NOTE: We must ask you to show ID if you are picking up your records. If someone other than

the parent/responsible party picks up records they will be required to present written permission to do so

from the parent/responsible party.

PLEASE SEE THE FOLLOWING PAGE OF THIS FORM FOR SPECIAL

DISCLOSURE INFORMATION REGARDING MENTAL HEALTH, DRUG AND/OR

ALCOHOL ABUSE, AND HIV-RELATED INFORMATION.

TO THE RECIPIENT OF THESE MATERIALS:

HIV/AIDS INFORMATION:

In the event that any of the disclosed information includes

HIV/AIDs information, this is protected under state law as follows:

“This information has been disclosed to you from records whose confidentiality is

protected by state law.

State law prohibits you from making any further

disclosure of it without the specific written consent of the person to whom it

pertains, or as otherwise permitted by said law. A general authorization for the

release of medical or other information is NOT sufficient for this purpose.” Any

oral disclosure shall by accompanied or followed by the above notice. See

Connecticut General Statute section 19a-585.

PSYCHIATRIC COMMUNICATIONS: If the released material contains confidential

psychiatric communication, as designated in C.G.S. sections 52-146d through 52-146i, inclusive,

please note the following:

“The confidentiality of this record is required under Chapter 899 of the

Connecticut general statutes. This material shall not be transmitted to anyone

without written consent or other authorization as provided in the aforementioned

statutes.”

A copy of the consent form setting forth any limitations shall

accompany the disclosure.

DRUG & ALCOHOL TREATMENT: No person, hospital, treatment facility or department of

health may disclose or permit the disclosure of the identity, diagnosis, prognosis or treatment of

any patient in a treatment for drug and\or alcohol abuse that would be in violation of federal or

state law. In the event that the records contain information regarding drug and\or alcohol abuse

treatment, please note the following legal requirements and prohibitions:

“This information has been disclosed to you from records protected by federal and

state confidentiality rules (42 C.F.R. Part 2). The federal rules prohibit you from

making any further disclosure of this information unless further disclosure is

expressly permitted by the written consent of the person to whom it pertains or as

otherwise permitted by 42 CFR part 2. A general authorization for the release of

medical or other information is NOT sufficient for this purpose. The federal rules

restrict any use of the information to criminally investigate or prosecute any

alcohol or drug abuse patient.” See Connecticut General Statute section 17a-688.

Hipaa Records Release - Greenwich Pediatrics Page 3