Cleveland clinic florida authorization to use and disclose protected health information form instructions 2025

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The document is an authorization form for the use and disclosure of protected health information (PHI) by Cleveland Clinic Florida. It requires the patient's personal details, specifies the types of health information to be disclosed, outlines the purpose of disclosure, and includes options for highly confidential information. The patient must sign to authorize this disclosure, understanding that they can revoke the authorization at any time. The document also provides contact information for the Privacy Office.

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Can protected health information PHI only be used accessed or disclosed after obtaining written authorization?

Yes. If requested by an individual, a covered entity must transmit an individuals PHI directly to another person or entity designated by the individual. The individuals request must be in writing, signed by the individual, and clearly identify the designated person or entity and where to send the PHI.

What is authorization to disclose health information in Florida?

Florida law requires patient authorization for disclosure of some sensitive health data with certain exceptions in medical emergencies. An authorization form can be used by a patient or his/her authorized legal representative to authorize a healthcare provider to obtain the patients records from another provider.

What can protected health information be disclosed without authorization?

A covered entity is permitted, but not required, to use and disclose protected health information, without an individuals authorization, for the following purposes or situations: (1) To the Individual (unless required for access or accounting of disclosures); (2) Treatment, Payment, and Health Care Operations; (3)

How to fill out authorization to disclose protected health information?

How do I fill out a HIPAA release form? Provide instructions. Name the patient and individual authorized to use or disclose their PHI. Describe the information. Specify recipients. Specify the purpose of disclosure. Specify the time period. Detail their revocation rights. Obtain the patients signature.

What does authorization to disclose health information mean?

Overview. A Privacy Rule Authorization is an individuals signed permission to allow a covered entity to use or disclose the individuals protected health information (PHI) that is described in the Authorization for the purpose(s) and to the recipient(s) stated in the Authorization.