Dhhs 4056 Patient Authorization English Spanish (Page 3 of 3) in pdf

PATIENT AUTHORIZATION

to Permit Use and Disclosure of Health Information (DHHS #4056)

This form implements the requirements for patient authorization to use and disclose health

information protected by the federal health privacy law, 45 C.F.R. parts 160, 164. Except as

otherwise permitted or required by the privacy law, a health care provider subject to the privacy

law may not use or disclose protected health information without an authorization that complies

with the requirements of 45 C.F.R. 164.508(c).

If the authorization is obtained to use or disclose information for marketing and the marketing

involves direct or indirect payment to the health care provider from a third party, the

authorization must state that such remuneration is involved.

[1] Person or class of persons

Indicate who may release (eg.,

authorized to use or disclose the

________ County Health Department staff).

information

[2] Person or class of persons to whom

Indicate by whom the information may be used

use or disclosure would be made

or to whom it may be disclosed (e.g., UNC-CH

School of Public Health).

[3] Purpose of use or disclosure

Describe why the information may be used or

disclosed (e.g., research). The statement “at the

request of the individual” is a sufficient

description of the purpose when an individual

initiates the authorization and does not, or elects

not to, provide a statement of the purpose.

[4] Name of covered entity

The local health department.

[5] NOTE: The federal privacy law permits a health care provider, in certain limited

circumstances, to condition the provision of health care on obtaining an authorization. For

example, a health care provider may condition the provision of health care that is solely for

the purpose of creating information for disclosure to a third party on an authorization

permitting such disclosure. Where the privacy rule permits the conditioning of services on

receipt of an authorization and the health care provider chooses to make treatment

conditional on the patient providing an authorization, then the sentence in this form

regarding the conditioning of the authorization must be modified to explain what the

condition is and the consequences to the patient of a refusal to sign the authorization.

[6] Date or event that relates to the

Indicate specific date or event after which

patient or the purpose of the use or

authorization is no longer valid (e.g., MM/DD/YY

disclosure

or “end of research study”). “None” is

acceptable if the authorization is for the creation

and maintenance of a research database or

research repository.

[7] Explain representative’s authority to

Identify source of authority for serving as patient

act on behalf of the patient

representative (e.g., parent or legal guardian).

105

Dhhs 4056 Patient Authorization English Spanish Page 3

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