HIPAA Authorization Form - New Mexico

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

(Comprehensive — HIPAA, NM Mental Health Code, NM HIV Test Act, NM Genetic Information Privacy Act, 42 C.F.R. Part 2)

1. DOCUMENT HEADER

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

2. DEFINITIONS

"Authorization" — This HIPAA authorization form, including any appendices.

"Covered Entity" or "CE" — The health-care provider, health plan, or health-care clearinghouse identified above, subject to HIPAA.

"Disclose" or "Disclosure" — The release, transfer, provision of access to, or divulging in any other manner of PHI outside CE, as those terms are used in 45 C.F.R. Section 160.103.

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

"Individual" — The subject of the PHI and signatory hereto.

"PHI" — Protected Health Information, including the categories specifically identified in Section 3.1.

"Recipient" — The person(s) or entity(ies) authorized to receive PHI as set forth in Section 1.

"Use" — The sharing, employment, application, utilization, examination, or analysis of PHI within CE.

3. OPERATIVE PROVISIONS

3.1 Description of Information to Be Used or Disclosed

CE is authorized to Use and Disclose the following categories of PHI (check all that apply):

☐ Complete medical record
☐ Office/clinic visit notes for the period [__/__/____] through [__/__/____]
☐ Laboratory and diagnostic test results
☐ Diagnostic imaging and radiology reports
☐ Discharge summaries and consultation reports
☐ Billing and claims records
☐ Immunization records
☐ Other: [____________________________________________]

3.2 Authorized Recipient(s)

Disclosure may be made to: [Recipient Name / Title / Address / Phone].

3.3 Purpose of Use or Disclosure

PHI may be Used or Disclosed solely for the following purpose(s):
☐ Continuity of care / treatment by another provider
☐ Payment, claims, or insurance underwriting
☐ Legal proceedings — Case No. [____________]
☐ Disability or workers' compensation claim
☐ Research study titled [____________]
☐ At the request of the Individual
☐ Other: [____________________________________________]

3.4 Expiration

This Authorization expires on the earliest of:
(a) [__/__/____];
(b) completion of the purpose stated in Section 3.3; or
(c) revocation under Section 3.6.

If no date is supplied, this Authorization expires one (1) year from the Effective Date.

3.5 Conditioning Prohibited

CE may not condition treatment, payment, enrollment, or eligibility for benefits on the execution of this Authorization, except as expressly permitted by 45 C.F.R. Section 164.508(b)(4).

3.6 Right of Revocation

Individual may revoke this Authorization at any time by delivering signed written notice to CE at [Designated Privacy Office / Address]. Revocation is effective on receipt but does not affect actions taken by CE or Recipient in reliance on this Authorization before revocation.

3.7 Re-Disclosure Warning

Information disclosed under this Authorization may be re-disclosed by Recipient and may no longer be protected by HIPAA or New Mexico law. PHI Disclosed pursuant to NMSA Section 24-2B-6 (HIV) and 42 C.F.R. Part 2 (substance use disorder) must be accompanied by the written prohibition-on-redisclosure statement required by those laws.

4. NEW MEXICO HEIGHTENED-PROTECTION CATEGORIES

The Individual specifically authorizes Disclosure of the following categories of sensitive information (initial only those authorized):

4.1 Mental Health Records (NMSA Section 43-1-19)

Confidential mental health and developmental-disabilities information acquired by a covered professional may not be disclosed without the Individual's authorization, except for the limited statutory exceptions (treatment-team access; imminent risk of serious physical injury or death; research subject to IRB review). By initialing the Mental Health line above, Individual authorizes Disclosure of the records described in Section 3.1 that constitute mental health or developmental-disabilities information.

4.2 HIV / AIDS Information (NMSA Section 24-2B-6)

HIV test results and related identifying information may not be disclosed except as authorized by the Human Immunodeficiency Virus Test Act. Any Disclosure made pursuant to this Authorization must be accompanied by a written statement that the information is protected by state law, that further disclosure without written consent is prohibited, and that unauthorized disclosure is a petty misdemeanor punishable under NMSA Section 24-2B-6.

4.3 Substance Use Disorder Records (42 C.F.R. Part 2; NMSA Section 43-2-22)

Federally protected substance use disorder records may be Disclosed only when the Individual has specifically initialed the corresponding line above and the Disclosure carries the Part 2 notice prohibiting redisclosure. This Authorization satisfies the written-consent requirements of 42 C.F.R. Sections 2.31 and 2.32 only to the extent the Individual has initialed the Substance Use category.

4.4 Genetic Information (NMSA Section 24-21-3)

Genetic information and the results of genetic analysis may not be obtained, retained, transmitted, or used without the Individual's informed and written consent, except as expressly permitted by the New Mexico Genetic Information Privacy Act. By initialing the Genetic line above, Individual provides such informed and written consent for the limited purpose stated in Section 3.3.

5. INDIVIDUAL RIGHTS AND ACKNOWLEDGMENTS

5.1 Right to a Copy. Individual is entitled to a signed copy of this Authorization upon request.

5.2 Right of Access. Individual retains the right of access to confidential information under NMSA Section 43-1-19(D) and 45 C.F.R. Section 164.524.

5.3 No Compensation for PHI. CE shall not receive remuneration for the Use or Disclosure of PHI except as permitted under HIPAA and New Mexico law.

5.4 Marketing and Sale. PHI may not be Used or Disclosed for marketing or sold to a third party unless a separate authorization expressly so provides.

5.5 Public Records Exception. Medical records held by a public hospital or other public entity remain exempt from disclosure under New Mexico's public-records framework, NMSA Section 14-6-1.

6. SIGNATURE AND EXECUTION

I have read this Authorization. I understand my rights described above, including my right to revoke this Authorization, the limits on re-disclosure, and the heightened protections applicable to sensitive information categories under New Mexico law. I am signing voluntarily.

Individual / Patient

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

If Signed by Personal Representative

Signature: _________________________________
Printed Name: _____________________________
Authority (parent, guardian, agent under power of attorney, executor): _____________________________
Documentation of Authority Attached: ☐ Yes ☐ No
Date: [__/__/____]

Witness (if required by facility policy)

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

7. SOURCES AND REFERENCES

• 45 C.F.R. Section 164.508 — HIPAA core authorization elements
• NMSA 1978, Section 43-1-19 — Mental health records; disclosure
• NMSA 1978, Section 24-2B-6 — HIV test results; confidentiality
• NMSA 1978, Section 43-2-22 — Alcohol and drug abuse records
• 42 C.F.R. Part 2 — Confidentiality of substance use disorder patient records
• NMSA 1978, Section 24-21-3 — Genetic Information Privacy Act
• NMSA 1978, Section 14-6-1 — Health-care information; public records exception