HIPAA Authorization Form Analysis

This assignment requires you to carefully examine a provided HIPAA authorization form. You need to identify and explain the different sections of the form, including the authorized recipients of information, the specific details that can be disclosed, limitations on disclosure (like alcohol/substance abuse, HIV/AIDS, or mental health), the purpose for which the information is used, the expiration date of the authorization, and any fees associated with copying patient records.

The release of information form available at (HPAF, 2017) evidentially indicates the
authorization of release of patient’s protected health information (PHI) with or without the
information related to HIV/AIDS, communicable diseases, substance (drug/alcohol) abuse or
mental health. HIPAA security convention advocates the requirement of protecting the PHI in
terms of its maintenance, configuration and confidentiality (CMS, 2016). HIPAA advocates
the requirement of transmitting health related information after obtaining individual
authorization (IOM, 2009). The same convention is duly followed in the information
disclosure form (HPAF, 2017) that descriptively provides the extent of authorization with
detailed clauses that need to be attested by the concerned patient before validation. HIPAA
privacy information form provides different options for disclosing or non-disclosing the PHI
related to mental health records, communicable diseases, drug abuse and alcohol addiction
(HPAF, 2017). The disclosure of protected health information regarding mental health or
substance abuse requires to any consumer reporting agency could relate to the requirement of
sharing individual information or payment history (HHS, 2013). The systematic sharing of
PHI in accordance with the health care operations requirements follows the 45 CFR 164.501
convention. The presented (HPAF, 2017) form does not provide the reason for disclosure of
information related to HIV or mental health, in case the consumer authorizes its release while
attesting the registered clause. HIPAA convention advocates the requirement of giving the
complete description of the requested information and identification of the authorised people
who can effectively release the protected health information.
The form – 2 provides an option for recording information of the PHI seekers
including their names and addresses. However, this form does not provide an option for
registering the complete description of the requested information. HIPAA conventions
provide a complete right to the health seeker in terms of revoking transmission of his/her PHI
under any circumstance (BIS, 2014). The form – 2 does provide the information-revoke-

clause for the health consumer for his/her utilization at any point in time. The ROI-form – 3
provides a descriptive clause of releasing the protected health information related to
psychiatry, HIV/AIDS and alcohol/drugs abuse. The form also mentions the re-disclosure
clause related to this shared information. This format rationally complies with the HIPAA
convention that clearly states the potential re-disclosure of the shared PHI in the absence of
any authorization (BIS, 2014). Such information is also not protected and governed by
HIPAA conventions. The HIPAA stipulations related to the PHI disclosure also advocates the
requirement of recording the identity of people who receive protected health information
from consumer’s medical facility (BIS, 2014).
The form – 3 effectively provides the option of recording the name, address and
telephone number of the PHI seekers. Furthermore, all of the ROI forms provide space for the
signature of patient/guardian in the context of validating the authorization form at any point
in time. This indicates their thorough compliance to the HIPAA clause that highlights the
requirement of patient attestation on the ROI form with the objective of releasing the
significant health information with the due consent of the patient or his/her guardian (BIS,
2014). The form – 3 also mentioned the information type (other than psychiatric/HIV/mental
health) that requires disclosure through patient’s consent. This also evidentially complies
with the clause – 1 of the HIPAA convention (BIS, 2014).
References

BIS (2014). Understanding the Release of Information Process. USA. Retrieved from
https://www.youtube.com/watch?v=8jrm9LYqpAY
CMS. (2016, Aug ). DEPARTMENT OF HEALTH AND HUMAN SERVICES _ CMS.
Retrieved from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-
Network-MLN/MLNProducts/Downloads/HIPAAPrivacyandSecurity.pdf
HHS. (2013). Uses and Disclosures for Treatment, Payment, and Health Care Operations.
Retrieved from
https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/disclosures-treatment-
payment-health-care-operations/index.html
HPAF. (2017). HIPAA Privacy Authorization Form. Retrieved 11 01, 2017, from
https://www.caring.com/forms/hipaa-release-form/free-hipaa-release-form.pdf
IOM. (2009). Beyond the HIPAA Privacy Rule: Enhancing Privacy, Improving Health
Through Research. In HIPAA, the Privacy Rule, and Its Application to Health
Research. USA: NAP.
Appendix

ROI Form – 1

SAMPLE ROI AUTHORIZATION FORM – 2
Patient’s Full Name Patient’s Social Security
Number/Medical Record Number
Address Patient’s Date of Birth
City, State Zip Code Patient’s Telephone Number
I hereby authorize use or disclosure of protected health information about me as described
below.
1. The following specific person/class of person/facility is authorized to use or disclose
information about me:
_____________________________________________________________________
__________________________________________
2. The following person (or class of persons) may receive disclosure of protected health
information about me:
His/her/its Name
Address
City, State Zip Code
3. The specific information that should be disclosed is (please give dates of service if
possible):
________________________________________________________________________
____________________________________
________________________________________________________________________
____________________________________
________________________________________________________________________
____________________________________
UNLESS YOU SIGN HERE, NO INFORMATION ABOUT
ALCOHOL/SUBSTANCE ABUSE, HIV/AIDS, OR MENTAL HEALTH WILL BE
DISCLOSED:
YES, DISCLOSE THIS INFORMATION *______________________
NO, DO NOT DISCLOSE THIS INFORMATION * ______________________

4. I understand that the information used or disclosed may be subject to re-disclosure by
the person or class of persons or facility receiving it, and would then no longer be
protected by federal privacy regulations.
5. I may revoke this authorization by notifying _______________________________ in
writing of my desire to revoke it. However, I understand that any action already taken
in reliance on this authorization cannot be reversed, and my revocation will not affect
those actions.
6. My purpose/use of the information is for
_____________________________________________________________________
______ .
7. This authorization expires on _____________, 200___, OR upon occurrence of the
following event that relates to me or to the purpose of the intended use or disclosure
of information about me: _____________________________________.
FEES FOR COPIES: Federal and state laws permit a fee to be charged for the
copying of patient records. This facility has contracted with HealthPort to make
copies. You may be required to pre-pay for the copies; if not, then your copies will
be mailed along with an invoice.
THIS FORM MUST BE FULLY COMPLETED BEFORE SIGNING – note that
signature is required in two places.*
__________________________
_________________
___________________
____________
_____________________
______________
Signature of Individual*
(The person about whom the
information relates)
Date of Individual’s
Signature
Date of Birth or
Social Security Number
OR, if applicable –
________________________________
_______
_______________________
________
_________________________
_________
Signature of Guardian* or
Personal Representative of Patient’s
Estate
Date of
Guardian’s/Personal
Representative’s Signature
Description of Authority to A
for the Individual
A copy of this completed, signed and dated form must be given to the Individual or
other signator.
Official Use Only
Received Processed By Log #

ROI Form – 3
Source: http://willamettevalleymedical.com/wp-content/uploads/2015/07/GUEST-
SERVICES-ROI-English.pdf