HIPAA Authorization Form - Michigan

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

(Comprehensive – HIPAA plus Michigan-specific sensitive-record protections)

TABLE OF CONTENTS

1. Document Header and Identification
2. Information to Be Used or Disclosed
3. Purpose, Recipients, and Expiration
4. Michigan Sensitive-Category Authorizations
5. Required HIPAA Statements and Rights
6. Re-Disclosure, Compensation, and Conditioning
7. Revocation
8. Representations and Signatures

1. DOCUMENT HEADER AND IDENTIFICATION

Effective Date: [__/__/____]

2. INFORMATION TO BE USED OR DISCLOSED

2.1 General Description. The Covered Entity is authorized to use and disclose the following Protected Health Information ("PHI") concerning the Patient:

☐ Complete medical record
☐ Records limited to dates of service from [__/__/____] to [__/__/____]
☐ Diagnostic and laboratory test results
☐ Diagnostic imaging and radiology reports
☐ Physician progress notes and consultation reports
☐ Discharge summaries and admission histories
☐ Medication and prescription records
☐ Billing, claims, and itemized statements
☐ Immunization records
☐ Other (specify): [_______________________________________]

2.2 Records Excluded From This General Authorization. Unless an additional initialed authorization is provided in Section 4, the following categories of records shall not be disclosed under this Authorization:

a. Psychotherapy notes (45 C.F.R. § 164.508(a)(2));
b. Mental health records governed by MCL § 330.1748;
c. HIV/AIDS-related records, test results, and partner-notification information governed by MCL § 333.5131;
d. Substance use disorder treatment records governed by 42 C.F.R. Part 2; and
e. Genetic test results and genetic information governed by MCL § 333.17020.

3. PURPOSE, RECIPIENTS, AND EXPIRATION

3.1 Authorized Recipient(s):

3.2 Purpose of Use or Disclosure (check all that apply):

☐ Continuity of care / treatment by another provider
☐ Personal use by the Patient ("at the request of the individual")
☐ Insurance underwriting, claims, or coverage determination
☐ Legal proceeding, Case No. [__________], court: [__________]
☐ Workers' compensation or disability claim
☐ Social Security / SSDI / Medicaid eligibility
☐ Research study titled [__________________________]
☐ Other (specify): [_______________________________________]

3.3 Expiration. This Authorization shall expire on the earliest of:
a. [__/__/____];
b. The event: [_____________________________]; or
c. Written revocation pursuant to Section 7.

If no expiration date or event is entered, this Authorization shall expire one (1) year from the Effective Date.

4. MICHIGAN SENSITIVE-CATEGORY AUTHORIZATIONS

4.1 Mental Health Records — MCL § 330.1748.

I specifically authorize disclosure of mental health records, including records and information acquired in the course of providing mental health services by a community mental health services program, licensed facility, or contract provider. I understand that under MCL § 330.1748 such information is confidential and may be disclosed only with my written consent or as otherwise authorized by law.

Patient Initials: [____] Date: [__/__/____]

4.2 Psychotherapy Notes — 45 C.F.R. § 164.508(a)(2).

I specifically authorize disclosure of psychotherapy notes maintained separately from the rest of the medical record.

Patient Initials: [____] Date: [__/__/____]

4.3 HIV / AIDS Information — MCL § 333.5131.

This is a written authorization specific to HIV infection and/or acquired immunodeficiency syndrome (AIDS) within the meaning of MCL § 333.5131(5). I expressly authorize the disclosure of any and all reports, records, data, partner-notification information, and other information pertaining to my HIV testing, HIV infection status, or AIDS diagnosis or treatment.

Specific information authorized for release (check all that apply):
☐ HIV test results (positive or negative)
☐ HIV-related diagnostic, clinical, and treatment records
☐ AIDS diagnosis and treatment records
☐ Antiretroviral / HIV medication records
☐ Partner-services / partner-notification information

Patient Initials: [____] Date: [__/__/____]

4.4 Substance Use Disorder Records — 42 C.F.R. Part 2.

I specifically authorize disclosure of records relating to the diagnosis, treatment, or referral for treatment of any substance use disorder, including alcohol use disorder, from a Part 2 program. I understand that these records are protected by federal law and that the recipient is generally prohibited from making any further disclosure of this information unless permitted by 42 C.F.R. Part 2 or by written consent.

Patient Initials: [____] Date: [__/__/____]

4.5 Genetic Test Information — MCL § 333.17020.

I specifically authorize disclosure of any presymptomatic or predictive genetic test results, the underlying sample, and related genetic information. I acknowledge that under MCL § 333.17020 a physician may not order such a test without my written informed consent, and that informed consent extends to the future use of the sample and information.

Patient Initials: [____] Date: [__/__/____]

5. REQUIRED HIPAA STATEMENTS AND RIGHTS

5.1 Right to Revoke. I understand that I have the right to revoke this Authorization in writing at any time, except to the extent that the Covered Entity has already taken action in reliance on it. See Section 7.

5.2 Treatment Conditioning. The Covered Entity may not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this Authorization, except as expressly permitted by 45 C.F.R. § 164.508(b)(4).

5.3 Potential for Re-Disclosure. I understand that information disclosed under this Authorization may be subject to re-disclosure by the recipient and may no longer be protected by HIPAA or Michigan law. Federal substance-use records (42 C.F.R. Part 2) and HIV/AIDS information (MCL § 333.5131) retain distinct re-disclosure restrictions even after release.

5.4 Right to Receive a Copy. I am entitled to receive a signed copy of this Authorization.

5.5 Identity Protection. Pursuant to MCL § 330.1748, when mental health information is disclosed, my identity shall be protected and shall not be disclosed unless germane to the authorized purpose.

6. RE-DISCLOSURE, COMPENSATION, AND CONDITIONING

6.1 Prohibition on Sale or Marketing. The Covered Entity shall not sell my PHI and shall not use or disclose it for marketing purposes without a separate authorization meeting the requirements of 45 C.F.R. § 164.508(a)(3)-(4).

6.2 Compensation. No party shall receive remuneration in exchange for the PHI disclosed under this Authorization except as expressly permitted by HIPAA.

6.3 Part 2 Notice (if Section 4.4 is initialed). The recipient is notified that 42 C.F.R. Part 2 prohibits unauthorized re-disclosure of records identifying a patient as having a substance use disorder. A general medical authorization is not sufficient for re-disclosure.

7. REVOCATION

I may revoke this Authorization at any time by delivering signed written notice to the Covered Entity at the address listed in Section 1 or to the HIPAA Privacy Officer. Revocation is effective on receipt, except to the extent the Covered Entity or recipient has already acted in reliance on this Authorization. Revocation does not affect any action taken before receipt of the revocation.

8. REPRESENTATIONS AND SIGNATURES

8.1 Patient Representations. I represent that (a) I am the Patient identified above or the legal representative authorized under Michigan and federal law to act on the Patient's behalf, (b) I have read and understand this Authorization, and (c) I am signing it voluntarily.

Patient / Recipient of Services

Signature: _________________________________
Printed Name: _____________________________
Date: [__/__/____]

Legal Representative (if applicable)

Signature: _________________________________
Printed Name: _____________________________
Relationship / Legal Authority (e.g., parent with legal custody of minor; guardian with authority to consent under Mental Health Code; patient advocate under MCL § 700.5506; personal representative / executor of estate of deceased recipient): _____________________________
Date: [__/__/____]

Witness (recommended)

Signature: _________________________________
Printed Name: _____________________________
Date: [__/__/____]

SOURCES AND REFERENCES

• 45 C.F.R. § 164.508 – HIPAA Authorization Required Elements
• MCL § 330.1748 – Mental Health Code; Confidentiality of Records
• MCL § 330.1748a – Mental Health Records; Child Abuse/Neglect Investigations
• MCL § 333.5131 – HIV/AIDS Confidentiality; Separate Written Authorization
• 42 C.F.R. Part 2 – Confidentiality of Substance Use Disorder Patient Records
• MCL § 333.17020 – Genetic Test; Written Informed Consent
• MCL § 333.26265 et seq. – Michigan Medical Records Access Act