HIPAA Authorization Form - New Jersey

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

(Comprehensive - HIPAA, NJ AIDS Assistance Act, NJ Genetic Privacy Act, and Mental Health / Substance Abuse Confidentiality Statutes)

TABLE OF CONTENTS

1. Document Header
2. Definitions
3. Operative Provisions
4. Sensitive-Category Authorizations (NJ)
5. Required HIPAA Notices
6. Representations and Warranties
7. Covenants and Restrictions
8. Default and Remedies
9. Dispute Resolution
10. General Provisions
11. Execution Block

1. DOCUMENT HEADER

HIPAA AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
Effective Date: [__/__/____]

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

Recitals

A. Covered Entity ("CE") maintains "Protected Health Information" ("PHI") pertaining to Individual that is subject to HIPAA, 45 C.F.R. Parts 160 and 164, and applicable New Jersey law, including N.J.A.C. § 8:43G-15 (hospital medical records).

B. Individual desires to authorize the Use and Disclosure of PHI described herein for the purpose(s) set forth below.

C. CE is willing to Use and Disclose PHI in reliance on this Authorization, and Recipient is willing to receive PHI, subject to HIPAA, New Jersey law, and the covenants below.

NOW, THEREFORE, the Parties agree as follows:

2. DEFINITIONS

"Authorization" - This HIPAA authorization form, including all appendices and amendments.

"Covered Entity" or "CE" - The health-care provider, health plan, hospital, or health-care clearinghouse identified in the Document Header.

"Disclose" or "Disclosure" - The release, transfer, provision of access to, or divulging in any manner of PHI outside CE, as defined in 45 C.F.R. § 160.103.

"HIPAA" - The Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191, and 45 C.F.R. Parts 160 and 164.

"Individual" - The subject of the PHI and signatory hereto, as defined in 45 C.F.R. § 160.103.

"NJ AIDS Act" - N.J.S.A. § 26:5C-1 et seq. (AIDS Assistance Act), governing the confidentiality and disclosure of HIV/AIDS records.

"NJ Genetic Privacy Act" - N.J.S.A. § 10:5-43 et seq.

"PHI" - Protected Health Information described as: [DESCRIBE CATEGORIES - e.g., "all medical records from [__/__/____] through [__/__/____]; lab results; imaging; physician notes; hospital discharge summaries"].

"Recipient" - The person(s) or entity(ies) authorized to receive the PHI.

"Use" - The sharing, employment, application, utilization, examination, or analysis of PHI within CE, as defined in 45 C.F.R. § 160.103.

3. OPERATIVE PROVISIONS

3.1 Grant of Authorization.
a. Authorized PHI. CE may Use and Disclose the PHI described above.
b. Authorized Recipient(s). Disclosure may be made to: [RECIPIENT NAME / TITLE / ADDRESS].
c. Purpose(s). PHI may be Used or Disclosed solely for: [e.g., "continuity of care," "insurance claim," "litigation in Docket No. [____]," "at Individual's request"].
d. Expiration. This Authorization expires on the earliest of: (i) [__/__/____]; (ii) completion of the purpose(s) in 3.1(c); or (iii) revocation under Section 3.2.

3.2 Right of Revocation.
Individual may revoke this Authorization at any time by delivering written notice to CE at [DESIGNATED ADDRESS / PRIVACY OFFICER]. Revocation is effective upon receipt, except to the extent CE or Recipient has acted in reliance.

3.3 Re-Disclosure Warning.
Information disclosed under this Authorization may be subject to re-disclosure by Recipient and may no longer be protected by HIPAA or New Jersey law. CE has no responsibility for re-disclosure not under its control.

3.4 Conditions for Treatment and Payment.
Except as permitted by 45 C.F.R. § 164.508(b)(4), CE may not condition treatment, payment, enrollment, or eligibility on the execution of this Authorization.

3.5 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 New Jersey law.

3.6 Copy of Authorization.
Individual is entitled to a signed copy of this Authorization. Initials: [____]

4. SENSITIVE-CATEGORY AUTHORIZATIONS (NEW JERSEY)

4.1 Mental Health Records (N.J.S.A. § 30:4-24.3; N.J.A.C. § 10:37-6.79).
Individual authorizes Disclosure of mental health records relating to evaluation, diagnosis, or treatment maintained by any provider, community agency, screening service, or short-term care or psychiatric facility.
☐ I authorize ☐ I do NOT authorize
Individual Initials: [____]

4.2 Psychotherapy Notes (45 C.F.R. § 164.508(a)(2)).
Individual authorizes Disclosure of psychotherapy notes maintained separately from the rest of the medical record.
☐ I authorize ☐ I do NOT authorize
Individual Initials: [____]

4.3 HIV / AIDS Records - SEPARATE WRITTEN INFORMED CONSENT (N.J.S.A. §§ 26:5C-7, 26:5C-8).
New Jersey requires prior written informed consent that is specific to HIV/AIDS information. By initialing below, Individual provides specific written informed consent to Disclosure of records identifying Individual as having or being suspected of having AIDS or HIV infection, including test results, diagnoses, treatment, and related information.

The records may be disclosed only to the Recipient identified in Section 3.1(b) and only for the purpose(s) stated in Section 3.1(c). The recipient is prohibited from further redisclosure of HIV/AIDS information without separate written informed consent of Individual, except as authorized by N.J.S.A. § 26:5C-8.

☐ I PROVIDE separate written informed consent for HIV/AIDS records
☐ I do NOT authorize HIV/AIDS Disclosure
Individual Initials: [____] Signature: __________________________ Date: [__/__/____]

4.4 Substance Use Disorder Records (42 C.F.R. Part 2; N.J.S.A. § 26:2B-20).
Federal law (42 C.F.R. Part 2) and New Jersey law restrict disclosure of records of Individual's identity, diagnosis, prognosis, or treatment relating to substance use disorder by a Part 2 program.
☐ I authorize ☐ I do NOT authorize
Individual Initials: [____]
Required Part 2 prohibition on re-disclosure: This information has been disclosed from records protected by federal confidentiality rules (42 C.F.R. Part 2). The federal rules prohibit further disclosure of this information unless authorized by Individual in writing or as otherwise permitted by 42 C.F.R. Part 2. The federal rules restrict any use of the information to investigate or prosecute with regard to a crime any patient with a substance use disorder, except as provided at §§ 2.12(c)(5) and 2.65.

4.5 Genetic Information (N.J.S.A. § 10:5-43 et seq.; GINA).
The NJ Genetic Privacy Act prohibits disclosure of the identity of any individual on whom a genetic test has been performed, or individually identifiable genetic information, except upon prior written informed consent.
☐ I authorize ☐ I do NOT authorize
Individual Initials: [____]

4.6 Reproductive Health, Sexually Transmitted Infections, and Sexual Assault Records.
☐ I authorize ☐ I do NOT authorize
Individual Initials: [____]

5. REQUIRED HIPAA NOTICES

5.1 Right to Revoke. As described in Section 3.2.

5.2 Treatment, Payment, Enrollment, and Eligibility. As described in Section 3.4.

5.3 Re-Disclosure. As described in Section 3.3, with category-specific limits under the NJ AIDS Act, NJ Genetic Privacy Act, and 42 C.F.R. Part 2.

5.4 Right to Inspect and Copy. Individual may inspect and obtain a copy of the PHI under HIPAA and applicable New Jersey hospital licensing regulations, including N.J.A.C. § 8:43G-15.

5.5 Fees. Copy fees shall comply with HIPAA's "reasonable, cost-based fee" standard at 45 C.F.R. § 164.524(c)(4) and applicable New Jersey caps.

6. REPRESENTATIONS AND WARRANTIES

6.1 Individual's Representations.
a. Individual is of legal age and has full legal capacity, or is the personal representative duly authorized under New Jersey law to sign on Individual's behalf.
b. The information provided is accurate and complete to the best of Individual's knowledge.

6.2 CE's Representations.
a. CE will Use and Disclose PHI only as permitted by this Authorization and applicable law.
b. CE maintains administrative, physical, and technical safeguards required by HIPAA, 45 C.F.R. Part 164, Subpart C.

6.3 Recipient's Representations.
Recipient shall maintain confidentiality of PHI in accordance with applicable law and this Authorization and shall not Use or Disclose PHI except as expressly permitted.

6.4 Survival.
The representations and warranties survive the expiration or termination of this Authorization to the extent necessary to protect PHI and enforce the Parties' rights.

7. COVENANTS AND RESTRICTIONS

7.1 Safeguards.
Recipient shall implement reasonable safeguards to prevent unauthorized Use or Disclosure of PHI and shall promptly notify CE and Individual of any breach or suspected breach.

7.2 Prohibited Actions.
Recipient shall not (a) sell PHI; (b) Use PHI for marketing without separate authorization; or (c) combine PHI with other data in violation of HIPAA, the NJ AIDS Act, the NJ Genetic Privacy Act, or other New Jersey law.

7.3 Sensitive-Category Compliance.
Recipient shall observe category-specific re-disclosure restrictions, including 42 C.F.R. Part 2 (substance use disorder), N.J.S.A. § 26:5C-8 (HIV/AIDS), N.J.S.A. § 30:4-24.3 (mental health), and N.J.S.A. § 10:5-47 (genetic).

8. DEFAULT AND REMEDIES

8.1 Events of Default.
a. Material breach of Sections 3, 4, or 7;
b. Failure to comply with any applicable law regarding PHI; or
c. Written notice of breach delivered by a governmental authority.

8.2 Notice and Cure.
Upon an Event of Default, the non-breaching Party shall give written notice specifying the default. The breaching Party shall have thirty (30) days from receipt to cure, if curable.

8.3 Remedies.
a. Termination of this Authorization, in whole or in part;
b. Injunctive relief to prevent unauthorized Disclosure;
c. Damages, civil penalties, and attorney fees as authorized by HIPAA, the NJ AIDS Act, the NJ Genetic Privacy Act, and other applicable law.

9. DISPUTE RESOLUTION

9.1 Governing Law.
This Authorization is governed by HIPAA and, to the extent not preempted, the laws of the State of New Jersey.

9.2 Forum Selection.
Exclusive jurisdiction and venue lie in the Superior Court of New Jersey, [COUNTY] County, and in the United States District Court for the District of New Jersey.

9.3 Equitable Relief.
Any equitable relief is limited to the minimum scope necessary to protect PHI.

10. GENERAL PROVISIONS

10.1 Amendment and Waiver. Amendments must be in writing and signed by all Parties.

10.2 Assignment. No Party may assign without prior written consent, except CE may assign to a successor in interest upon merger or acquisition.

10.3 Severability. Invalid provisions shall be reformed to the minimum extent necessary; the remainder continues in full force.

10.4 Integration. This Authorization is the entire agreement on its subject matter.

10.5 Counterparts and Electronic Signatures. Counterparts permitted; electronic signatures deemed equivalent under the New Jersey Uniform Electronic Transactions Act, N.J.S.A. § 12A:12-1 et seq.

11. EXECUTION BLOCK

IN WITNESS WHEREOF, the Parties have executed this Authorization as of the Effective Date.

Individual / Patient

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

If signed by Personal Representative:
Printed Name: [__________________________________]
Authority / Relationship: [__________________________________]
Documentation Attached: ☐ Power of Attorney ☐ Guardianship Order ☐ Other: [____________]

Covered Entity

By: ____________________________________
Printed Name: [__________________________________]
Title: [__________________________________]
Date: [__/__/____]

Witness (Required for HIV/AIDS disclosure under N.J.S.A. § 26:5C-8 if no personal signature; recommended for all sensitive-category disclosures)

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

SOURCES AND REFERENCES

• 45 C.F.R. § 164.508 (HIPAA authorization core elements)
• 42 C.F.R. Part 2 (substance use disorder records confidentiality)
• N.J.S.A. § 30:4-24.3 (mental health records confidentiality and exceptions)
• N.J.S.A. § 26:5C-1 et seq. (AIDS Assistance Act)
• N.J.S.A. § 26:5C-7 (Confidentiality of AIDS, HIV records)
• N.J.S.A. § 26:5C-8 (Disclosure of AIDS, HIV records)
• N.J.S.A. § 26:2B-20 (substance abuse treatment records confidentiality)
• N.J.S.A. § 10:5-43 et seq. (NJ Genetic Privacy Act)
• N.J.A.C. § 8:43G-15 (hospital medical records)
• N.J.S.A. § 12A:12-1 et seq. (NJ Uniform Electronic Transactions Act)