HIPAA Authorization Form - Alaska

AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION

HIPAA and Alaska Representative-Authority Companion

Complete every applicable field. Under 45 C.F.R. § 164.508, an authorization
with an incomplete required element can be defective.

1. Individual

Do not include a Social Security number unless the disclosing organization
requires it and provides a secure process.

2. Person or Organization Authorized to Disclose

I authorize the following person, organization, or specifically identified
class to use or disclose the information described in Section 4:

Name or specific identification: [________________________________]

Address or location: [________________________________]

Department, provider, or class, if applicable: [________________________]

☐ One discloser only

☐ The specifically identified class above

Do not use “all providers” unless the intended class is sufficiently specific
for the organizations relying on the form to identify themselves.

3. Recipient

The information may be disclosed to:

List every recipient or a sufficiently specific class. State whether multiple
recipients receive the same information.

4. Information Authorized

Date or event range

From [DATE / EVENT] through [DATE / EVENT]

Selected records

☐ Entire designated record set for the period above, subject to stated
exclusions

☐ Office or progress notes

☐ History and physical examinations

☐ Consultation reports

☐ Laboratory results

☐ Imaging reports

☐ Images or radiographic studies: [FORMAT / SPECIFIC STUDY]

☐ Operative or procedure reports

☐ Discharge summaries

☐ Medication list or prescription history

☐ Billing and payment records

☐ Immunization records

☐ Other specifically described information: [________________________]

Excluded information

[IDENTIFY RECORDS, DATES, PROVIDERS, OR SUBJECTS THAT MUST NOT BE DISCLOSED]

The description must be specific and meaningful.

Special-record screen

Do not use this ordinary form for psychotherapy notes. Under 45 C.F.R.
§ 164.508(a)(2) and (b)(3)(ii), psychotherapy notes generally require an
authorization and that authorization may be combined only with another
authorization for psychotherapy notes.

If the requested material may include substance-use-disorder records governed
by 42 C.F.R. Part 2, minor-consented care, mental-health commitment or treatment
records, sexually transmitted infection records, genetic information, or
another specially protected category, the disclosing organization must decide
whether this form is sufficient or a separate consent, authorization, notice,
or legal process is required.

5. Purpose

☐ At my request

☐ Continuing care with [RECIPIENT]

☐ Insurance or benefit matter described as [________________________]

☐ Legal matter described as [________________________]

☐ Other specific purpose: [________________________________]

Select “at my request” only when that is the actual purpose.

6. Expiration Date or Event

This authorization expires on:

☐ [MM/DD/YYYY]

☐ Completion of this event related to the individual or purpose:
[CLEARLY DESCRIBED EVENT]

An expiration date or event must be completed. Revocation is a separate right
under Section 8 and is not the form's only expiration event.

7. Required Statements

Potential redisclosure

I understand that information disclosed under this authorization may be
redisclosed by the recipient and may no longer be protected by the HIPAA
Privacy Rule. Another law may still protect the information.

Conditioning

Select the statement verified by the covered entity:

☐ The covered entity will not condition treatment, payment, enrollment in a
health plan, or eligibility for benefits on whether I sign this authorization.

☐ The covered entity may condition [RESEARCH-RELATED TREATMENT / PRE-
ENROLLMENT HEALTH-PLAN DETERMINATION / HEALTH CARE SOLELY TO CREATE PHI FOR A
THIRD-PARTY DISCLOSURE] on this authorization as permitted by 45 C.F.R.
§ 164.508(b)(4). The consequences of refusing are:
[________________________________]

Do not select the second statement without privacy-office or counsel approval.

Marketing or sale involving remuneration

☐ No marketing or sale of protected health information involving remuneration
is intended

☐ Marketing involving financial remuneration to the covered entity is
intended; required statement: [________________________________]

☐ A disclosure that is a sale of protected health information is intended;
required remuneration statement: [________________________________]

An applicable authorization must satisfy 45 C.F.R. § 164.508(a)(3)-(4).

8. Right to Revoke

I may revoke this authorization at any time by a written revocation delivered
to:

Privacy office or designated person: [________________________________]

Approved delivery route: [________________________________]

The revocation will not affect action already taken in reliance on the
authorization. If the authorization was obtained as a condition of insurance
coverage, other law may preserve an insurer's right to contest a claim or the
policy. Additional revocation instructions appear at:
[NOTICE OF PRIVACY PRACTICES / WRITTEN PROCEDURE / LOCATION].

9. Signature

By signing, I authorize the use or disclosure described above. I have had an
opportunity to read this completed form.

Individual

Signature: ______________________________________

Printed name: [________________________________]

Date: [__/__/____]

Personal representative, if applicable

Signature: ______________________________________

Printed name: [________________________________]

Date: [__/__/____]

Description of authority:
[AGENT / GUARDIAN / SURROGATE / PARENT / PERSONAL REPRESENTATIVE / OTHER,
INCLUDING LIMITS, EFFECTIVE STATUS, AND SUPPORTING DOCUMENT]

Supporting authority reviewed by: [NAME / ROLE / DATE]

AS 13.52.070(a) gives a person then authorized to make health-care decisions
the patient's rights to request, receive, examine, copy, and consent to
disclosure of medical or other health-care information unless the advance
directive says otherwise. Subsection (b) allows an agent or surrogate immediate
access to information necessary to determine capacity when capacity is in
question, even if the agency or surrogacy becomes effective only upon lack of
capacity. That limited access does not establish authority for every record or
purpose.

A relationship label alone does not prove that a parent, spouse, child,
sibling, agent, guardian, or surrogate may sign. Verify current authority,
capacity findings, availability, priority, limitations, disqualification, and
any contrary directive or order.

10. Processing Record

This section documents processing; it is not a recipient contract.

11. Defect and Escalation Checklist

Return or escalate the form if:

☐ the individual, discloser, recipient, information, purpose, expiration, or
signature is blank or insufficiently specific

☐ the expiration date passed or event occurred

☐ the authorization is known to have been revoked

☐ material information is known to be false

☐ the form improperly combines this authorization with another document

☐ psychotherapy notes are included without the permitted separate form

☐ conditioning is inconsistent with 45 C.F.R. § 164.508(b)(4)

☐ a required marketing or sale remuneration statement is missing

☐ representative authority is absent, inactive, limited, or disputed

☐ another confidentiality law requires a different or additional route

Individual's Copy

☐ A copy of the signed, completed authorization was provided to the individual
on [DATE] by [METHOD].

This authorization is complete only when every required field is filled and
the disclosing organization accepts it for the specific records and purpose.