Home And Community Based Services Manual 900 APPENDIX

home and community based services manual ======================================== 9.00 appendix 6 authorization for disclosure of

Home and Community Based Services Manual
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9.00
APPENDIX 6
AUTHORIZATION FOR DISCLOSURE OF CONSUMER MEDICAL/HEALTH INFORMATION
INSTRUCTIONS
T he Authorization for Disclosure of Consumer Medical/Health
Information (Authorization) is a statewide form implemented by
multiple state agencies, including the Department of Health and Senior
Services (DHSS), in response to the Health Insurance Portability and
Accountability Act of 1996 (HIPAA) as amended by the Health
Information Technology for Economic and Clinical Health Act (HITECH)
(PL-111-5) (collectively, and hereinafter, HIPAA). This form serves as
written documentation to obtain and/or release protected health
information (PHI) as required by HIPAA. PHI is defined as any
individually identifiable health information which would include:
*
Participant case record information;
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Demographic information (name, address, date of birth, etc.); and
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Physical and mental health information contained in the case.
This form provides maximum protection for the participant’s privacy
and serves as a legal means of documenting the participant’s
permission for information sharing. Use of this form also documents
what information is released and the purpose of the disclosure. This
form shall be completed any time PHI will be released in hard copy
form to a person or entity other than the participant, guardian, or
other legal representative. It may also be used to document permission
to share information verbally, when necessary (see Policy 9.00).
The authorization becomes effective on the date of signature and
expires one year from that date, unless it is revoked by the
participant prior to that time.
INSTRUCTIONS:
This form shall be typed or clearly written in ink prior to being
signed by the participant. No blank or partially completed forms are
to be signed by the participant. DSDS staff completing the form shall
review all the information contained in the document with the
participant.
Page 1
Enter the name of the person authorizing the release of the
medical/health information about the participant. This may be the
participant, a legal guardian, or an individual named as a durable
power of attorney for health care (DPOA-HC) that has been invoked.
*
If the authorizing individual is not the participant, a copy of
the document granting legal authority to act on behalf of the
participant must be attached.
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If the person is deceased, the document granting legal authority
would be papers appointing a personal representative.
Check the appropriate box to indicate the entity providing
medical/health information about the participant. When using the
‘Other’ box, enter the name of the specific entity.
Enter the participant’s full legal name, Departmental Client Number
(DCN), and date of birth.
Enter the Social Security Number only if the participant does not have
an assigned DCN.
L ist the specific dates of services included in the requested
records. The phrase “any and all” is not specific and shall not be
used.
Check the appropriate box to indicate the entity that will receive the
information. When using the ‘Other’ box, enter the name of the
specific entity and complete the address information.
Check all applicable purposes for the disclosure. If the boxes
provided are not applicable, mark “other” and write in the purpose.
Check all applicable information to be disclosed. When the requested
information is not listed, mark other and provide a description of the
specific information.
Page 2
Review entire first section with the participant.
Obtain the participant’s signature (when there is no legal guardian or
DPOA-HC) and enter the date signed.
Obtain witness signature and enter the date signed.
Obtain signature of legal guardian, DPOA-HC, or other legal
representative, when applicable.
*
This signature should match the name of the person authorizing
disclosure.
When form is completed to request disclosure of substance abuse
treatment information, the participant must also review, sign and date
this section.
Revocation
This section shall be completed if the participant, or the individual
with legal authority to act as representative for the participant,
wishes to revoke the authorization. The participant or representative
must send the form to the department, facility, agency, or entity
indicated at the beginning of the form.
Enter the date of revocation.
Enter the participant’s name.
Obtain signature of the participant or their legal representative, as
appropriate.
DISTRIBUTION:
One copy shall be provided to the participant/representative. A copy
shall be sent to the agency disclosing/releasing the information, and
a copy shall be uploaded into the participant’s case record in the
HCBS Web Tool.
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