HIPAA Authorization Form - Missouri

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

Compliant with 45 C.F.R. § 164.508 and Missouri-specific privacy statutes

1. INDIVIDUAL (PATIENT) INFORMATION

2. PERSON OR ENTITY AUTHORIZED TO DISCLOSE PHI (Covered Entity)

3. PERSON OR ENTITY AUTHORIZED TO RECEIVE PHI (Recipient)

4. SPECIFIC DESCRIPTION OF PHI TO BE USED OR DISCLOSED

☐ Complete medical record
☐ Records limited to dates of service: [__/__/____] through [__/__/____]
☐ Specific records (check all that apply):
☐ Physician progress notes / office visit notes
☐ Hospital admission/discharge summaries
☐ Laboratory results
☐ Diagnostic imaging (X-ray, MRI, CT, ultrasound) and reports
☐ Operative reports / surgical records
☐ Medication / prescription history
☐ Immunization records
☐ Billing and itemized statements
☐ Emergency Department records
☐ Other: [_______________________________]

4A. Missouri Sensitive Information — Separate Initials Required

Missouri law and federal law require specific, separate written authorization before the following categories may be disclosed. Initialing below authorizes disclosure of each indicated category. Failure to initial means the category is NOT released, even if "complete medical record" is checked above.

5. PURPOSE OF USE OR DISCLOSURE

☐ At the request of the Individual
☐ Continuing care / treatment by new provider
☐ Personal use / personal records
☐ Insurance claim, underwriting, or eligibility determination
☐ Legal proceeding — Case Caption / No.: [_______________________________]
☐ Workers' compensation claim
☐ Social Security Disability / SSI application
☐ Veterans Affairs / military benefits
☐ Employment — pre-employment or fitness-for-duty
☐ Education / school enrollment
☐ Research study: [_______________________________]
☐ Other: [_______________________________]

6. EXPIRATION

This Authorization expires on the earliest of:

☐ Date: [__/__/____]
☐ Event: [_______________________________] (e.g., "conclusion of Case No. ____" or "one year from signature")
☐ One (1) year from the date of signature, if no other date or event is specified

7. RIGHT TO REVOKE

I understand I may revoke this Authorization in writing at any time by delivering a signed revocation to the Covered Entity's Privacy Officer at the address in Section 2. Revocation is effective upon receipt except to the extent the Covered Entity has already acted in reliance on this Authorization. 42 C.F.R. Part 2 substance use records require revocation to be honored prospectively only.

Written revocation address: [_______________________________]

8. REQUIRED HIPAA NOTICES (45 C.F.R. § 164.508(c)(2))

8.1 Conditioning Prohibited. The Covered Entity may not condition treatment, payment, enrollment in a health plan, or eligibility for benefits on whether I sign this Authorization, except (a) for research-related treatment, (b) for the sole purpose of creating PHI for disclosure to a third party, or (c) for enrollment/underwriting where permitted.

8.2 Re-Disclosure Warning. Information used or disclosed under this Authorization may be re-disclosed by the Recipient and may no longer be protected by HIPAA. Missouri sensitive categories listed in Section 4A retain heightened state-law protection, and re-disclosure of:

• HIV/AIDS information without separate written consent violates RSMo § 191.656 and exposes the discloser to civil liability (actual or liquidated damages of $1,000, costs, attorney fees);
• Substance use disorder records is restricted by 42 C.F.R. Part 2 and may require a separate Part 2-compliant authorization;
• Mental health records is restricted by RSMo § 630.140;
• Genetic information is restricted by RSMo § 375.1309.

8.3 Right to Copy. I am entitled to a signed copy of this Authorization.

8.4 No Compensation. No Party shall receive remuneration for the Use or Disclosure of PHI except as permitted under HIPAA, 45 C.F.R. § 164.508(a)(4), and Missouri law.

9. METHOD OF DELIVERY

☐ Secure encrypted email to: [_______________________________]
☐ U.S. Mail to address in Section 3
☐ Fax to: [_______________________________]
☐ Hand pick-up by Individual or designated representative
☐ Patient portal / electronic health record release
☐ Other: [_______________________________]

Format requested: ☐ Paper copies ☐ Electronic (PDF) ☐ CD/DVD ☐ Original films/images

10. SIGNATURE

I have read this Authorization (or had it read to me), understand its contents, and agree to the disclosures described above. I confirm I have initialed each sensitive category in Section 4A that I intend to authorize.

Individual / Patient

Signature: ____________________________________

Printed Name: ________________________________

Date: [__/__/____]

If signed by Personal Representative:

Printed Name: ________________________________

Signature: ____________________________________

Relationship / Legal Authority (check one):
☐ Parent of minor
☐ Court-appointed guardian/conservator (attach order)
☐ Durable Power of Attorney for Health Care (attach)
☐ Personal representative of decedent's estate (attach letters)
☐ Other: [_______________________________]

Date: [__/__/____]

Witness (optional, recommended for sensitive disclosures):

Signature: ____________________________________ Printed Name: ________________________________ Date: [__/__/____]

11. SOURCES AND REFERENCES

• 45 C.F.R. § 164.508 — HIPAA Authorization core elements and notices
• 42 C.F.R. Part 2 — Confidentiality of Substance Use Disorder Patient Records
• RSMo § 630.140 — Mental health records confidentiality (Missouri Dept. of Mental Health)
• RSMo § 191.656 — Confidentiality of HIV/AIDS test results; civil remedies
• RSMo § 191.317 — Substance abuse treatment records
• RSMo § 198.526 — Long-term care resident records
• RSMo § 376.1550 — Genetic information
• RSMo § 375.1303 / § 375.1309 — Genetic information confidentiality (insurance)
• Missouri Revisor of Statutes: https://revisor.mo.gov