HIPAA Authorization Form - Delaware

AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION

HIPAA and Delaware Representative-Authority Companion

Complete every applicable field. Under 45 C.F.R. § 164.508, an authorization
that is incomplete as to a required element is 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

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

The description must identify the information in a specific and meaningful
fashion.

Date or event range

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

Selected records

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

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, minor-consented,
mental-health, HIV, genetic, reproductive-health, or another specially
protected category of information, the disclosing organization must determine
whether a different or additional 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 the individual initiated the authorization
and does not provide another 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
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 the additional statements in
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: [__/__/____]

Relationship or legal capacity: [________________________________]

Description of authority to act for the individual:
[________________________________]

Authority document reviewed by the disclosing organization:
[________________________________]

Under 45 C.F.R. § 164.502(g), representative status depends on applicable law
and the scope of the person's authority. A Delaware agent or default surrogate
may have the health-information authority described in 16 Del. C. § 2518(b).
For an agent appointed by a Delaware power of attorney for health care, state
whether the document makes that information power effective on appointment as
permitted by § 2518(c). This form does not appoint an agent or default
surrogate.

10. Copy and Processing

If the covered entity seeks this authorization, it must provide the individual
with a copy of the signed authorization under 45 C.F.R. § 164.508(c)(4).

☐ Copy provided to the individual or representative

Date provided: [__/__/____]

Method: [________________________________]

Received by covered entity: [__/__/____] at [____:____] ☐ a.m. ☐ p.m.

Processed by: [________________________________]

Disclosure date and scope: [________________________________]

Sources and References

• 45 C.F.R. § 164.508 — current eCFR bulk XML
• 45 C.F.R. § 164.502(g) — current eCFR bulk XML
• 16 Del. C. § 2518

End of Template