HIPAA Authorization Form - Montana

HIPAA / MONTANA UNIFORM HEALTH CARE INFORMATION ACT AUTHORIZATION

Compliant with 45 C.F.R. § 164.508 and Montana Uniform Health Care Information Act, MCA § 50-16-501 et seq.

1. INDIVIDUAL (PATIENT) INFORMATION

2. HEALTH CARE PROVIDER AUTHORIZED TO DISCLOSE (Covered Entity)

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

4. NATURE OF INFORMATION TO BE DISCLOSED

☐ Complete health care record
☐ Records limited to dates of service: [__/__/____] through [__/__/____]
☐ Specific records (check all that apply):
☐ Physician / clinician progress notes
☐ Hospital admission and discharge summaries
☐ Laboratory test 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. Montana Heightened-Protection Categories — Separate Initials Required

Montana law (and federal law) requires 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 health care 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 (see MCA § 50-16-527 for special rules)
☐ 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. ____")
☐ Six (6) months from the date of signature, if no other date or event is specified

7. RIGHT TO REVOKE

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 health care provider has already acted in reliance on this Authorization. 42 C.F.R. Part 2 substance use records and disclosures already made are not affected.

Written revocation address: [_______________________________]

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

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) 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. Montana heightened-protection categories in Section 4A retain state-law protections, and re-disclosure of:

• HIV/AIDS information without separate authorization violates MCA § 50-16-1009 and is punishable as a misdemeanor (up to $1,000 fine and/or 1 year imprisonment);
• Substance use disorder records is restricted by 42 C.F.R. Part 2 — a separate Part 2-compliant consent is required;
• Mental health records is restricted by MCA § 53-21-166;
• Genetic information is restricted by MCA §§ 33-18-901 et seq.

8.3 Non-Waiver of Other Rights. Per MCA § 50-16-526(3), signing this Authorization is not a waiver of any rights I have under other Montana statutes, the Montana Rules of Evidence, or common law (including physician-patient and mental-health-professional/client privilege, MCA § 26-1-807).

8.4 Right to Copy. I am entitled to a signed copy of this Authorization (45 C.F.R. § 164.508(c)(4); MCA § 50-16-531).

8.5 No Compensation. No Party shall receive remuneration for the use or disclosure of health care information except as permitted under HIPAA, 45 C.F.R. § 164.508(a)(4), and Montana 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 heightened-protection category in Section 4A that I intend to authorize. I understand that under MCA § 50-16-526, a valid authorization must be in writing, dated, and signed by me, and must identify the nature of the information and the recipient.

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
• MCA § 50-16-501 et seq. — Montana Uniform Health Care Information Act
• MCA § 50-16-526 — Patient authorization to health care provider for disclosure
• MCA § 50-16-527 — Authorization retention, effective period, workers' comp exception
• MCA § 50-16-531 — Provider immunity; form requirements
• MCA § 53-21-166 — Confidentiality of mental health records
• MCA § 50-16-1009 — HIV/AIDS confidentiality; criminal penalty for unlawful disclosure
• MCA § 53-24-301 — Substance abuse treatment records
• MCA §§ 33-18-901 to 33-18-906 — Restrictions on use of genetic information (insurance)
• MCA § 26-1-807 — Mental health professional-client privilege
• Montana Code Annotated: https://leg.mt.gov