Massachusetts Department Of Public Health Authorization For Release Of Information Permission To Share Information

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Massachusetts Department of Public Health
Authorization for Release of Information
Permission to Share Information
If you want the ________________________to share information about you with another person or
(Fill in name of person or organization)
organization, please make sure that you fill out all of the sections below (Sections I-VI). This will tell us what
information you want us to share and who to share it with. If you leave any sections blank, with the exception of
Section II (B), your permission will not be valid, and we will not be able to share your information with the person(s)
or organization you listed on this form.
SECTION I
I,
, give my permission for _______________________
(print your name)
(Fill in name of person or
organization)
to share the information about me that I list in Section II with the person(s) or organization that I list in Section V.
SECTION II
A. Health and Personal Information
Please describe the information you want the _______________________ to share about you.
(Fill in name of person or organization)
Please include any dates and details you want to share.
B. Permission about Specific Health Information. Only if you choose to share any of the following
information, please write your initials on the line:
_____I specifically give permission, as required by M.G.L. c. 111, § 70F, to share information in my record about HIV
antibody and antigen testing, and HIV/AIDS diagnosis or HIV/AIDS treatment.
____I specifically give permission, as required by M.G.L. c. 111, §70G, to share information in my record about my
genetic information.
____I specifically give permission to share information in my record about alcohol or drug treatment. If this
information is shared, I understand that a specific notice required by 42 CFR, Part 2 shall be included prohibiting the
redisclosure of this confidential information.
SECTION III – Reason for Sharing this Information
Please describe the reason(s) for sharing this information. If you do not want to list reasons, you may simply write:
“at my request,” if you are initiating the request.
SECTION IV – Who May Share This Information
I give permission to the person or organization listed below to share the information I listed in Section II:
Name
Organization
Address
1
HIPAA-compliant Authorization 9/08 Form 5-A

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