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93 DBHDS AUTHORIZATION FOR USE/DISCLOSURE OF ...

93 DBHDS AUTHORIZATION FOR USE/DISCLOSURE OF ... 2026

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The document is an 'Authorization for Release of Information' form that allows a patient to consent to the disclosure of their protected health information (PHI) under HIPAA regulations. It specifies the types of information that can be disclosed, the purpose for the disclosure, and includes sections for patient and facility witness signatures. The form emphasizes the patient's right to limit disclosures and revoke authorization, while also highlighting legal protections against further disclosure of sensitive information related to alcohol or drug abuse treatment.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the patient's name, date of birth, and social security number in the designated fields. Ensure accuracy as this information is crucial for identification.
In the section labeled 'Extent or nature of disclosure', check all applicable boxes that indicate what information you wish to disclose, such as discharge summaries or treatment plans.
Specify the purpose for the disclosure in the provided field. This helps clarify why the information is being shared.
Fill in the names of individuals or entities with whom you are authorizing information exchange. Be precise to avoid any confusion.
Review the authorization statement carefully. Once satisfied, sign and date at the bottom of the form to validate your consent.
If you need to cancel permission later, complete the cancellation section at the end of the document and sign again.

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What is the authorization for disclosure of information form used for?

A HIPAA authorization form gives covered entities permission to use protected health information for purposes other than treatment, payment, or health care operations. Continue reading to find out when authorization to disclose health information is needed.

What is a HIPAA authorization for use or disclosure?

Authorization. A covered entity must obtain the individuals written authorization for any use or disclosure of protected health information that is not for treatment, payment or health care operations or otherwise permitted or required by the Privacy Rule.

What is an authorization for use or disclosure of PHI?

Under the Privacy Rule, a covered entity may use or disclose protected health information pursuant to a copy of a valid and signed Authorization, including a copy that is received by facsimile or electronically transmitted.

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