Consent to Use and Disclose Protected Health Information form 2025

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When Must Patient Authorization be Obtained for Uses and Disclosures of PHI? Authorizations are generally required for psychotherapy notes, substance abuse disorder and treatment records, and for marketing purposes.
Disclosure means a release to persons or entities other than to the patient who is the subject of the information. Medical Record includes information Mayo uses to make health care decisions about a patient.
A HIPAA release form is a document that when signed allows healthcare providers to share a patients protected health information (PHI) with specified individuals or organizations, ing to the details stipulated in the form.
Obtaining consent (written permission from individuals to use and disclose their protected health information for treatment, payment, and health care operations) is optional under the Privacy Rule for all covered entities.
The general rule under the Privacy Act is that an agency cannot disclose a record contained in a system of records unless the individual to whom the record pertains gives prior written consent to the disclosure. There are twelve exceptions to this general rule.

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I, the undersigned, authorize the release of, or request access to the information specified below from the medical record(s) of the above name patient. I understand that my records are confidential and cannot be disclosed without my written authorization, except when otherwise permitted by law.

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