HIPAA Authorization Form - Oklahoma

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

(Comprehensive — HIPAA, 42 C.F.R. Part 2, and Oklahoma Mental Health, HIV, and Genetic Privacy Law)

TABLE OF CONTENTS

1. Document Header
2. Definitions
3. Operative Provisions
4. Representations & Warranties
5. Covenants & Restrictions
6. Default & Remedies
7. Risk Allocation
8. Dispute Resolution
9. General Provisions
10. Execution Block

1. DOCUMENT HEADER

HIPAA AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
Effective Date: [MM/DD/YYYY]

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

a. Individual / Patient: [Full Legal Name], DOB [MM/DD/YYYY] ("Individual");
b. Covered Entity: [Health-Care Provider / Plan / Clearinghouse Legal Name] ("Covered Entity" or "CE"); and
c. Recipient(s): [Name(s) or Specific Identification of Recipient(s)] ("Recipient").

Recitals

A. CE maintains "Protected Health Information" ("PHI") pertaining to Individual that is subject to the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations, 45 C.F.R. Parts 160 and 164 ("HIPAA").
B. Individual desires to authorize the Use and Disclosure of PHI as described herein for the purpose(s) set forth below, subject to applicable Oklahoma law, including Okla. Stat. tit. 43A § 1-109 and tit. 63 § 1-502.2.
C. CE is willing to Use and Disclose PHI in reliance on this Authorization, and Recipient is willing to receive PHI, all subject to HIPAA, 42 C.F.R. Part 2 (where applicable), and the additional covenants, limitations, and remedies provided below.

NOW, THEREFORE, in consideration of the mutual promises contained herein, 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, or health-care clearinghouse identified in the Document Header that is 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. § 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, as that term is used in 45 C.F.R. § 160.103.

"Oklahoma Mental Health Law" — Okla. Stat. tit. 43A § 1-109 and related provisions governing the confidentiality of mental health, alcohol, and drug abuse treatment information.

"PHI" — Protected Health Information, including [describe categories, e.g., "physician progress notes, laboratory results dated [MM/DD/YYYY] to [MM/DD/YYYY], diagnostic imaging, discharge summaries, and billing records"].

"Recipient" — The person(s) or entity(ies) authorized to receive the PHI, as set forth in Section 3.1(b).

"Use" — The sharing, employment, application, utilization, examination, or analysis of PHI within CE, as those terms are used in 45 C.F.R. § 160.103.

3. OPERATIVE PROVISIONS

3.1 Grant of Authorization.
a. Authorized PHI. CE is hereby authorized to Use and Disclose the PHI specifically described in the definition of "PHI" 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 the following purpose(s): [e.g., "continuity of care," "insurance underwriting," "legal proceeding in Case No. ____ pending in the District Court of ____ County, Oklahoma," "at the request of the Individual"].
d. Expiration. This Authorization shall expire on the earliest to occur of:
(i) [MM/DD/YYYY];
(ii) completion of the purpose(s) stated in Section 3.1(c); or
(iii) revocation pursuant to 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 or HIPAA Privacy Office]. Revocation is effective upon receipt, except to the extent CE or Recipient has already acted in reliance on this Authorization. Consistent with Okla. Stat. tit. 43A § 1-109, revocation does not affect any action taken before the revocation was received.

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, 42 C.F.R. Part 2, or Oklahoma law. CE shall have no responsibility for any re-disclosure not under its control. Initials: ☐ [____]

3.4 Conditions for Treatment and Payment.
Except for research-related treatment or enrollment in a health plan, CE may not condition treatment, payment, enrollment, or eligibility for benefits on the execution of this Authorization. 45 C.F.R. § 164.508(b)(4).

3.5 Special Categories of PHI — Oklahoma-Specific Initials Required.

3.6 42 C.F.R. Part 2 Notice (Substance Use Disorder Records).
If this Authorization extends to records protected by 42 C.F.R. Part 2, Individual acknowledges receipt of the following notice required by 42 C.F.R. § 2.32:

"This information has been disclosed to you from records protected by federal confidentiality rules (42 C.F.R. Part 2). The federal rules prohibit you from making any further disclosure of information in this record that identifies a patient as having or having had a substance use disorder either directly, by reference to publicly available information, or through verification of such identification by another person unless further disclosure is expressly permitted by the written consent of the individual whose information is being disclosed or as otherwise permitted by 42 C.F.R. Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose."

3.7 Compensation / No Sale of PHI.
No Party shall receive remuneration for the Use or Disclosure of PHI except as permitted under HIPAA, 42 C.F.R. Part 2, and Oklahoma law. 45 C.F.R. § 164.508(a)(4).

4. REPRESENTATIONS & WARRANTIES

4.1 Individual's Representations.
a. Individual is of legal age and has full legal capacity, or is the personal representative duly authorized under Oklahoma law to sign this Authorization on behalf of the patient.
b. The information provided herein is accurate and complete.

4.2 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 45 C.F.R. Part 164, Subpart C.

4.3 Recipient's Representations.
Recipient shall maintain the confidentiality of PHI in accordance with all applicable laws and this Authorization, and shall not Use or Disclose PHI except as expressly permitted herein.

5. COVENANTS & RESTRICTIONS

5.1 Safeguards.
Recipient shall implement reasonable administrative, physical, and technical safeguards to prevent unauthorized Use or Disclosure of PHI and shall immediately notify CE and Individual of any breach or suspected breach.

5.2 Prohibited Actions.
Recipient shall not:
a. Sell PHI;
b. Use PHI for marketing without separate written authorization satisfying 45 C.F.R. § 164.508(a)(3); or
c. Combine PHI with other data in a manner that violates HIPAA, 42 C.F.R. Part 2, or Oklahoma law.

6. DEFAULT & REMEDIES

6.1 Events of Default.
a. Material breach of any provision of Sections 3-5;
b. Failure to comply with any applicable law regarding PHI; or
c. Written notice of breach delivered by a governmental authority.

6.2 Remedies.
a. Termination of this Authorization, in whole or in part;
b. Limited Injunctive Relief to prevent imminent or continuing unauthorized Disclosure of PHI;
c. Recovery of Direct Damages subject to statutory limits, including those expressly provided in Okla. Stat. tit. 63 § 1-502.2 (court costs, attorney fees, exemplary damages, and actual damages for wrongful disclosure of HIV-related information).
d. Attorney Fees. The prevailing Party is entitled to reasonable attorney fees and costs incurred in enforcing this Authorization to the extent permitted by Oklahoma law.

7. RISK ALLOCATION

7.1 Indemnification.
Recipient shall indemnify, defend, and hold harmless CE and its affiliates from and against any third-party claims, losses, or liabilities directly arising out of Recipient's Use or Disclosure of PHI in violation of this Authorization or applicable law.

7.2 Limitation of Liability.
To the fullest extent permitted by law, the aggregate liability of any Party under this Authorization shall not exceed the statutory damages or penalties expressly authorized by HIPAA, 42 U.S.C. § 1320d-5, 42 C.F.R. Part 2, Okla. Stat. tit. 63 § 1-502.2, and related Oklahoma law. In no event shall any Party be liable for incidental or consequential damages, except as expressly provided by statute.

8. DISPUTE RESOLUTION

8.1 Governing Law.
This Authorization shall be governed by HIPAA and, to the extent not preempted, the laws of the State of Oklahoma.

8.2 Forum Selection.
The Parties consent to exclusive jurisdiction and venue in the state and federal courts located in [COUNTY], Oklahoma.

8.3 Jury Trial.
Nothing in this Section shall be construed to waive any Party's constitutional right to a jury trial under Article II, § 19 of the Oklahoma Constitution.

9. GENERAL PROVISIONS

9.1 Amendment & Waiver.
Any amendment must be in writing and signed by all Parties.

9.2 Severability.
If any provision is held invalid or unenforceable, it shall be reformed to the minimum extent necessary, and the remaining provisions shall continue in full force.

9.3 Integration.
This Authorization constitutes the entire agreement among the Parties concerning the subject matter and supersedes all prior understandings.

9.4 Counterparts & Electronic Signatures.
This Authorization may be executed in counterparts. Electronic signatures are deemed equivalent to handwritten signatures for all purposes under the Oklahoma Uniform Electronic Transactions Act, Okla. Stat. tit. 12A § 15-101 et seq.

10. EXECUTION BLOCK

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

Individual / Patient

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

If signing as Personal Representative (parent, guardian, attorney-in-fact under Okla. Stat. tit. 58 § 1071 et seq., or court-appointed representative):
Authority / Relationship: _____________________
Documentation Attached: ☐ Yes ☐ No

Covered Entity

By: __________________________ Title: ____________________
Printed Name: _____________________________
Date: [__/__/____]

Recipient (if signature required)

By: __________________________ Title: ____________________
Printed Name: _____________________________
Date: [__/__/____]

Witness (Recommended for Mental Health / Substance Abuse / HIV Disclosures)

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

SOURCES AND REFERENCES

• 45 C.F.R. § 164.508 — HIPAA authorization core elements
• 42 C.F.R. Part 2 — Confidentiality of Substance Use Disorder Patient Records
• Okla. Stat. tit. 43A § 1-109 — Confidential and privileged information; release requirements for mental health and substance abuse records
• Okla. Stat. tit. 63 § 1-502.2 — Communicable disease (including HIV) confidentiality and wrongful disclosure liability
• Okla. Stat. tit. 76 § 19 — Access to medical records; privilege waiver in personal injury actions; mental health carve-out
• Okla. Stat. tit. 36 § 3614.3 — Disclosure of genetic information
• Genetic Information Nondiscrimination Act (GINA), 42 U.S.C. § 2000ff et seq.