HIPAA Authorization Form - Connecticut

AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION

Connecticut — General HIPAA Form with State-Law Gate

Complete every required field. This form does not decide whether Connecticut
requires a different form, additional wording, initials, witnesses,
notarization, expiration, representative authority, or recipient restriction.
Resolve Section 1 before signature.

1. STATE AND SPECIAL-RECORD OVERLAY

Reviewer and date: [________________________________] / [__/__/____]

Attached authority/form: [________________________________]

2. INDIVIDUAL

3. PERSON OR CLASS AUTHORIZED TO DISCLOSE

I authorize the following person(s) or specifically identified class to make the
use or disclosure described below:

4. INFORMATION TO BE USED OR DISCLOSED

Describe the information in a specific and meaningful fashion.

Provider, facility, plan, or source: [________________________________]

Date range: [__/__/____] through [__/__/____]

• ☐ Billing records
• ☐ Medication list
• ☐ Laboratory results
• ☐ Diagnostic imaging and reports
• ☐ History and physical
• ☐ Progress or office notes
• ☐ Operative/procedure reports
• ☐ Discharge summary
• ☐ Immunization records
• ☐ Other specifically described information: [________________________________]

Records excluded: [________________________________]

Do not use “all records” unless that scope is intended, legally permitted, and
approved under Section 1.

5. PERSON OR CLASS AUTHORIZED TO RECEIVE

6. PURPOSE

• ☐ At my request
• ☐ Continuing care
• ☐ Insurance or benefits matter
• ☐ Legal matter identified as: [________________________________]
• ☐ Other specific purpose: [________________________________]

If the individual initiated the authorization and elects not to state another
purpose, “at my request” may be used. A special-purpose authorization may
require different wording.

7. EXPIRATION

This authorization expires on one completed date or event related to me or the
purpose of the disclosure:

☐ Date: [__/__/____]

☐ Event: [________________________________]

Revocation is separate from expiration and does not replace this required field.

8. RIGHT TO REVOKE

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

Name/office: [________________________________]

Address, email, or approved route: [________________________________]

Revocation will not affect action already taken in reliance on this
authorization. If the authorization was obtained as a condition of insurance
coverage, revocation is also subject to any other law giving the insurer a
right to contest a claim or the policy.

9. CONDITIONING NOTICE

Select the accurate statement:

☐ The covered entity may not condition treatment, payment, enrollment, or
eligibility for benefits on whether I sign this authorization.

☐ The covered entity may condition [________________________________] on this
authorization under 45 C.F.R. § 164.508(b)(4). If I refuse to sign, the
consequence is: [________________________________].

Do not select the second option without approval of the exact regulatory
exception.

10. REDISCLOSURE NOTICE

Information disclosed under this authorization may be redisclosed by the
recipient and may no longer be protected by the HIPAA Privacy Rule. Other
federal or Connecticut confidentiality law may continue to restrict the recipient.

11. ACKNOWLEDGMENTS

By signing, I confirm that:

• the information, discloser, recipient, purpose, and expiration are complete;
• I understand the revocation, conditioning, and redisclosure statements;
• I have had an opportunity to ask questions; and
• I am entitled to a copy of this signed authorization.

This authorization is the individual's permission. It does not create a
three-party contract; impose recipient warranties, indemnity, default, cure,
attorney-fee, arbitration, forum, insurance, force-majeure, or liability-cap
terms; or authorize a disclosure prohibited by other law.

12. SIGNATURE

Individual

Signature: __________________________________

Printed name: [________________________________]

Date: [__/__/____]

Personal representative — complete only if applicable

Representative signature: __________________________________

Printed name: [________________________________]

Authority to act: [________________________________]

Supporting document reviewed/attached: [________________________________]

Date: [__/__/____]

The releasing entity must verify the representative's authority for every
identified record.

13. RELEASING ENTITY CONTROL

Reviewed by: [________________________________]

Date: [__/__/____]

Disclosure log/reference: [________________________________]