HIPAA Authorization Form - Florida

FLORIDA AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION

Complete every applicable blank. An incomplete authorization may be invalid. This form is for an individual-directed disclosure of ordinary health information; it is not a contract among the patient, provider, and recipient.

1. Individual

2. Person or Organization Authorized to Disclose

I authorize the following specifically identified person, provider, facility, health plan, or class of persons to use or disclose the information described below:

Name or class: [____________________________________________________________]

Address/contact: [__________________________________________________________]

Additional disclosing persons or organizations: [________________________________]

3. Information Authorized for Use or Disclosure

The information must be described specifically and meaningfully. Check and complete only what is intended.

• ☐ Records created from [__/__/____] through [__/__/____]
• ☐ Entire medical record for the following episode or course of care: [________________]
• ☐ Office, progress, consultation, or treatment notes: [____________________________]
• ☐ Laboratory, pathology, or diagnostic-test results: [____________________________]
• ☐ Imaging reports and images: [________________________________________________]
• ☐ Medication and prescription records: [________________________________________]
• ☐ Billing, insurance, and payment records: [_____________________________________]
• ☐ Discharge summaries or operative reports: [___________________________________]
• ☐ Other specifically described information: [____________________________________]

Unless a separately reviewed authorization is completed, this form does not authorize disclosure of psychotherapy notes, substance-use-disorder records governed by 42 C.F.R. part 2, HIV-related information, Florida mental-health clinical records, or genetic/DNA information.

4. Recipient

I authorize disclosure to the following specifically identified person, organization, or class of persons:

Name or class: [____________________________________________________________]

Address/contact or secure delivery destination: [_______________________________]

5. Purpose

The purpose of the requested use or disclosure is:

• ☐ At my request
• ☐ Continuing care with: [_____________________________________________________]
• ☐ Insurance, benefits, or claim administration: [_______________________________]
• ☐ Legal matter identified as: [________________________________________________]
• ☐ Other specific purpose: [___________________________________________________]

6. Expiration

Choose and complete one expiration date or event related to the individual or the stated purpose:

• ☐ This authorization expires on [__/__/____].
• ☐ This authorization expires when the following event occurs: [___________________].

Revocation is addressed separately below and is not a substitute for completing an expiration date or event.

7. Revocation

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

Privacy office/person: [______________________________________________________]

Address or approved delivery method: [________________________________________]

The revocation will not affect action already taken in reliance on this authorization. If this authorization was obtained as a condition of insurance coverage, other law may permit the insurer to contest a claim or the policy.

8. Treatment, Payment, Enrollment, or Benefits

The person obtaining this authorization must select and complete the applicable statement:

• ☐ Signing is not a condition of treatment, payment, enrollment in a health plan, or eligibility for benefits.
• ☐ Signing is permitted to be a condition in this situation. If I refuse to sign, the consequences are: [____________________________________________________________].

9. Redisclosure and Florida Use Limitation

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

For treatment records released by a Florida hospital or ambulatory surgical center under Fla. Stat. § 395.3025, a recipient other than me or my representative may use the information only for the purpose stated above and may not further disclose it unless my written consent expressly permits that further disclosure. A general authorization is not sufficient to permit further disclosure.

Choose one:

• ☐ I do not authorize the recipient to disclose the information further.
• ☐ I expressly authorize the recipient to disclose the following information to the following person for the following purpose only:

Information: [____________________________________________________________]

Further recipient: [_______________________________________________________]

Purpose: [____________________________________________________________]

10. Signature

By signing, I authorize the use or disclosure described in this completed form.

Individual’s signature: [____________________________________________________]

Printed name: [____________________________________________________________]

Date signed: [__/__/____]

If Signed by a Personal Representative

Representative’s signature: [_______________________________________________]

Printed name: [____________________________________________________________]

Authority to act for the individual: [________________________________________]

Date signed: [__/__/____]

Attach or identify documentation of authority if requested by the disclosing person or organization.

Processing Checklist — Not Part of the Authorization

• ☐ The information, disclosing person, recipient, purpose, and expiration are complete.
• ☐ The revocation method and applicable conditioning statement are complete.
• ☐ The form is written and presented in plain language.
• ☐ Any specially protected category is excluded or covered by a separately reviewed authorization.
• ☐ The signer received a copy of the signed authorization.
• ☐ The disclosing covered entity retained the signed authorization as required by its HIPAA documentation procedures.

Official Sources

• 45 C.F.R. § 164.508 — current eCFR bulk XML
• Fla. Stat. § 456.057
• Fla. Stat. § 395.3025