HIPAA Authorization Form - Maine

HIPAA AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION (MAINE)

(HIPAA and Maine Health Information Privacy Act Compliant)

1. DOCUMENT HEADER

HIPAA AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

Effective Date: [__/__/____]

This HIPAA Authorization ("Authorization") is made by and between:

a. Individual/Patient: [Full Legal Name] ("Individual");
b. Covered Entity: [Health-Care Provider / Plan / Clearinghouse Legal Name] ("Covered Entity" or "CE"); and
c. Recipient(s): [Name(s) or Specific Identification of Recipient(s)] ("Recipient").

2. INDIVIDUAL AND RECIPIENT INFORMATION

Disclosing Party (Covered Entity):

Receiving Party (Recipient):

3. DESCRIPTION OF INFORMATION TO BE DISCLOSED

I authorize the Covered Entity to use and disclose the Protected Health Information ("PHI") described below. The description is specific and meaningful as required by 45 C.F.R. § 164.508(c)(1)(i) and 22 M.R.S. § 1711-C.

Categories of records (check all that apply):

• ☐ All medical records
• ☐ Office/progress/visit notes (specify dates: [__/__/____] to [__/__/____])
• ☐ Hospital/discharge records
• ☐ Laboratory test results
• ☐ Diagnostic imaging and radiology reports
• ☐ Prescription/medication history
• ☐ Billing and itemized statements
• ☐ Immunization records
• ☐ Other: [________________________________]

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

4. SPECIAL CATEGORIES OF INFORMATION (MAINE-PROTECTED)

I specifically authorize disclosure of the following protected categories. I must initial each line to authorize disclosure of that category. Failure to initial means that category is NOT authorized for disclosure.

5. PURPOSE OF DISCLOSURE

The purpose of this disclosure is (check or specify; 45 C.F.R. § 164.508(c)(1)(iv) requires a specific purpose):

• ☐ At the request of the Individual (no further description required)
• ☐ Continuity of care / transfer to new provider
• ☐ Legal proceedings (Case No.: [____________])
• ☐ Insurance claim or benefits determination
• ☐ Disability determination (SSA, ERISA, private)
• ☐ Personal review by Individual
• ☐ Employment-related evaluation
• ☐ Research study: [____________________]
• ☐ Other (specify): [________________________________]

6. EXPIRATION

This Authorization shall expire upon the earliest of:

• ☐ Date certain: [__/__/____]
• ☐ Event: [_________________________] (e.g., "conclusion of Case No. ____" or "end of treatment")
• ☐ One (1) year from the date signed below (default if no other selection)

7. RIGHT TO REVOKE

Pursuant to 45 C.F.R. § 164.508(c)(2)(i) and 22 M.R.S. § 1711-C, I understand:

a. I may revoke this Authorization at any time by delivering written notice to the Covered Entity at the Privacy Officer address listed in Section 2.
b. Revocation takes effect on receipt by the Covered Entity, EXCEPT to the extent the Covered Entity or Recipient has already taken action in reliance on this Authorization prior to receipt of the revocation.
c. Revocation will not affect disclosures already made.

8. RE-DISCLOSURE WARNING

I understand that:

a. Once PHI is disclosed under this Authorization, the Recipient may re-disclose it, and the information may no longer be protected by HIPAA or Maine law.
b. Substance Use Disorder Records (5 M.R.S. § 20047 and 42 C.F.R. Part 2): Federal law prohibits any re-disclosure of these records without specific written consent of the Individual or as otherwise permitted by 42 C.F.R. Part 2. A general authorization for release of medical information is NOT sufficient.
c. HIV/AIDS records (5 M.R.S. § 19203): Subject to additional Maine confidentiality protections; re-disclosure restricted.
d. Mental Health Records (34-B M.R.S. § 1207): Subject to additional Maine confidentiality protections; re-disclosure restricted.

9. CONDITIONING

Pursuant to 45 C.F.R. § 164.508(b)(4), the Covered Entity may not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this Authorization, except as permitted for:

• Research-related treatment (164.508(b)(4)(i));
• Health plan eligibility/enrollment underwriting (164.508(b)(4)(ii)); or
• Disclosures solely for creating PHI for a third party (164.508(b)(4)(iii)).

10. COMPENSATION FOR DISCLOSURE

• ☐ I understand the Covered Entity WILL NOT receive remuneration for the disclosure of my PHI.
• ☐ I understand the Covered Entity WILL receive remuneration as follows: [____________________] (45 C.F.R. § 164.508(a)(4)).

11. METHOD OF DELIVERY

PHI shall be delivered to Recipient by (select all that apply):

• ☐ U.S. Mail (standard)
• ☐ U.S. Mail (certified, return receipt)
• ☐ Secure electronic transmission / encrypted email
• ☐ Patient portal
• ☐ Fax to: [____________________]
• ☐ Hand delivery / in-person pickup
• ☐ Other: [____________________]

12. STATEMENT OF UNDERSTANDING

By signing below, I acknowledge and agree:

1. I have read and understood this Authorization in its entirety, or it has been read and explained to me.
2. I am signing voluntarily and free from coercion.
3. I have had the opportunity to ask questions and to consult an attorney if I wished.
4. I am entitled to a copy of this signed Authorization (45 C.F.R. § 164.508(c)(4)).
5. I understand my rights under HIPAA, 22 M.R.S. § 1711-C, and other applicable Maine privacy statutes.

13. EXECUTION

If signed by a personal representative (parent of minor, legal guardian, healthcare agent under advance directive, or executor):

Witness (recommended; required by some Maine facilities for certain disclosures):

14. COPY TO PATIENT

☐ A copy of this completed and signed Authorization has been provided to the Individual on [__/__/____] as required by 45 C.F.R. § 164.508(c)(4).

SOURCES AND REFERENCES

• 45 C.F.R. § 164.508 (HIPAA Authorization Core Elements)
• 22 M.R.S. § 1711-C (Maine Health Information Privacy Act): https://legislature.maine.gov/legis/statutes/22/title22sec1711-C.html
• 34-B M.R.S. § 1207 (Mental Health Confidentiality): https://legislature.maine.gov/statutes/34-b/title34-Bsec1207.html
• 5 M.R.S. § 19203 (HIV Testing and Disclosure Confidentiality)
• 5 M.R.S. § 20047 (Substance Use Disorder Records Confidentiality)
• 42 C.F.R. Part 2 (Federal Substance Use Disorder Records)
• 42 U.S.C. § 1320d-5 (HIPAA Civil Penalties)