Authorization Form For Use Or Disclosure Of Protected Health Information - Sedgwick County, Kansas

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Sedgwick County, Kansas

AUTHORIZATION FORM FOR USE OR DISCLOSURE OF

PROTECTED HEALTH INFORMATION

’

LIENT

AME

IRTH DATE

DDRESS

CHECK ONE:

(“PHI”)

HEREBY AUTHORIZE

EDGWICK

OUNTY TO USE PROTECTED HEALTH INFORMATION

CONCERNING THE ABOVE

NAMED PERSON OR TO DISCLOSE

PHI

TO THE FOLLOWING

_______________________________________________________________________________________________________________________

Name(s) of person(s)/organization(s) or class(es) of persons/organizations to which disclosure is to be made.

PHI

HEREBY AUTHORIZE

TO DISCLOSE

CONCERNING THE ABOVE

NAMED PERSON TO

EDGWICK

OUNTY

For treatment date(s): ______________________________

_______________________________

Starting Date

Ending Date

For the following purpose(s): ________________________________________________________________________________________________

If the request is initiated by the individual (or his/her representative), insert “at the request of individual”; otherwise, describe purpose of the use or disclosure. If

the purpose relates to marketing, indicate whether Sedgwick County will receive remuneration.

HECK TYPE OF

NFORMATION

UTHORIZED

SED AND

ISCLOSED

Unless the appropriate box is checked, Sedgwick County will not disclose or use PHI prepared by health care

providers not affiliated with Sedgwick County unless the PHI were prepared on behalf of Sedgwick County.

Demographic Information

Physician Progress Notes

Entire Record (will not include billing

records or records not prepared by or on behalf

Payment Records

Physician Orders

of Sedgwick County unless those items also are

Lab Test Results

Discharge Summary

selected).

Admission History & Physical

Nursing Notes

Consultation Reports

Billing Records

Records not prepared by or on behalf of

Sedgwick County. Sedgwick County cannot be

Operative/Procedure Reports

Therapy Notes

responsible for the completeness or accuracy of

Imaging/Radiology Reports

Other _________________________

such records.

This authorization shall remain in effect until

(date) or

(occurrence of specified

event) at which time this authorization to disclose the identified PHI expires, but no later than one year from the date listed below. If

this item is left blank, the authorization shall remain effective for 360 days after the date listed below.

_____ 1) I understand that my records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient

Records, 42 CFR Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I

may revoke this consent at any time except to the extent that action has been taken in reliance on it, and that in any event, this consent expires

automatically as stated above;

____ 2) I understand this may include information relating to diagnosis and treatment of mental, alcoholic, drug dependency, or emotional

condition, other than notes recorded by a mental health professional documenting or analyzing conversation during a counseling session provided

such notes are maintained separately (unless this authorization pertains specifically to psychotherapy notes);

____ 3) I understand this may include information relating to HIV testing, HIV status, or AIDS. I understand that such information is subject to

special protections pursuant to state and federal laws and regulations.

By my initials, I authorize the use or disclosure of records containing such information if they are otherwise included within the scope of this

authorization.

I, the undersigned, have read the above and authorize the disclosure of such PHI as described. I understand that treatment is not conditioned upon the execution of this

authorization. I understand that if the person or entity that receives the information is not a health care provider or health plan covered by federal privacy regulations,

the information described above may be re-disclosed and is no longer protected by those regulations.

I understand Sedgwick County may charge fees to provide copies of records, and will apply guidelines and fee schedules established for compliance with the Kansas

Open Records Act to this purpose. I understand that I may revoke this authorization at any time by providing a written notice to the person identified below except to

the extent that action has been taken in reliance upon it or except as otherwise stated in Sedgwick County’s “Notice” of Privacy Practices by mailing or hand-

delivering written notification to the following person: Department Privacy Office. (Please see additional page for mailing and contact information.)

__________________

__________________________________________________

Date

Signature of Individual/Individual Representative

___________________________________________

______________________________________________________

Printed Name of Representative and Relationship

Representative address and telephone number

____________ ______________

Date

Signature of Witnessing Sedgwick County Employee