HIPAA Authorization Form - Pennsylvania

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

(Comprehensive — HIPAA and Pennsylvania Confidentiality Laws)

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. CE maintains certain Protected Health Information ("PHI") pertaining to Individual that is subject to HIPAA, 45 C.F.R. Parts 160 and 164, and Pennsylvania law.
B. Individual desires to authorize the Use and Disclosure of PHI as described herein, subject to the terms below and applicable Pennsylvania law.
C. CE is willing to Use and Disclose PHI in reliance on this Authorization, subject to HIPAA, Pennsylvania law, and the covenants below.

2. DEFINITIONS

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

"Covered Entity" or "CE" — The health-care provider, health plan, or clearinghouse identified above 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 used in 45 C.F.R. § 160.103.

"HIPAA" — The Health Insurance Portability and Accountability Act of 1996 and its implementing regulations at 45 C.F.R. Parts 160 and 164.

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

"PA Confidentiality Laws" — Collectively, 50 P.S. § 7111 (Mental Health Procedures Act), 35 P.S. §§ 7601–7612 (Confidentiality of HIV-Related Information Act), 71 P.S. § 1690.108 (Drug and Alcohol Abuse Control Act), 28 Pa. Code § 115.27 (hospital records), 40 P.S. § 908-3 (genetic information), and 55 Pa. Code Chapter 5100.

"PHI" — Protected Health Information, including [describe categories, e.g., "laboratory test results dated __/__/____ through __/__/____, diagnostic imaging, physician progress notes, and 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.

3. OPERATIVE PROVISIONS

3.1 Grant of Authorization

a. Authorized PHI. CE is hereby authorized to Use and Disclose the PHI specifically 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 underwriting," "legal proceeding in Case No. ____," "research study titled ____," or "at the request of the Individual"].
d. Expiration. This Authorization shall expire on the earliest to occur of:
(i) [__/__/____];
(ii) completion of the purpose(s) stated above; 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. For HIV-related information, revocation rights are also expressly preserved under 35 P.S. § 7607.

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 Pennsylvania law. For substance use disorder records subject to 42 C.F.R. Part 2: the federal rules prohibit any further disclosure of records protected by Part 2 unless further disclosure is expressly permitted by the written consent of the person to whom the records pertain 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.

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.

3.5 Special Categories of PHI — Pennsylvania-Specific Authorizations Required

Each category below requires the Individual's separate, specific written consent. Initial each category authorized for disclosure; leaving a category un-initialed prohibits its disclosure.

a. Mental Health Records (50 P.S. § 7111; 55 Pa. Code Ch. 5100). All documents concerning persons in mental-health treatment are confidential and may not be released without the person's specific written consent. Privileged communications may NEVER be disclosed absent such written consent.
☐ Initials: [____] — I specifically authorize release of mental health records.
☐ Initials: [____] — I specifically authorize release of privileged communications.

b. HIV-Related Information (35 P.S. § 7607). Confidential HIV-related information requires a specific written authorization separately naming the discloser, the recipient, and the purpose. A general authorization is NOT sufficient.
☐ Initials: [____] — I specifically authorize release of HIV-related information.
Recipient (HIV info): [_______________________]
Purpose (HIV info): [_______________________]

c. Substance Use Disorder Records (71 P.S. § 1690.108 and 42 C.F.R. Part 2). SUD records may not be disclosed without the patient's specific written consent satisfying the elements of 42 C.F.R. § 2.31.
☐ Initials: [____] — I specifically authorize release of substance use disorder records.

d. Psychotherapy Notes (45 C.F.R. § 164.508(a)(2)).
☐ Initials: [____] — I specifically authorize release of psychotherapy notes.

e. Genetic Information (40 P.S. § 908-3; GINA). Genetic test results may be disclosed only consistent with the Genetic Information Nondiscrimination Act and Pennsylvania insurance restrictions on genetic information.
☐ Initials: [____] — I specifically authorize release of genetic information.

f. Hospital Records (28 Pa. Code § 115.27). Hospital records are confidential and released only upon written authorization or other legally recognized basis.
☐ Initials: [____] — I specifically authorize release of hospital records.

3.6 Compensation

No Party shall receive remuneration for the Use or Disclosure of PHI except as permitted under HIPAA and Pennsylvania law.

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 Pennsylvania law to sign this Authorization.
b. The information provided herein is accurate and complete to the best of Individual's knowledge.

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 HIPAA and the PA Confidentiality Laws.

4.3 Recipient's Representations

Recipient shall maintain the confidentiality of PHI in accordance with HIPAA, the PA Confidentiality Laws, and this Authorization, and shall not Use or Disclose PHI except as expressly permitted herein.

4.4 Survival

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

5. COVENANTS & RESTRICTIONS

5.1 Recipient Covenant

Recipient shall implement reasonable 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; or
c. Combine PHI with other data in a manner that violates HIPAA or Pennsylvania law.

5.3 Institutional Procedures for HIV Information

Per 35 P.S. § 7607(c), institutional health care providers with access to confidential HIV-related information must maintain written procedures for confidentiality and disclosure.

6. DEFAULT & REMEDIES

6.1 Events of Default

a. Material breach of Sections 3–5;
b. Failure to comply with HIPAA, the PA Confidentiality Laws, or 42 C.F.R. Part 2; or
c. Written notice of breach from a governmental authority.

6.2 Notice & Cure

Upon an Event of Default, the non-breaching Party shall give written notice. The breaching Party shall have [30] days to cure, if curable.

6.3 Remedies

a. Termination of this Authorization, in whole or in part;
b. Limited Injunctive Relief to prevent imminent or continuing unauthorized Disclosure;
c. Recovery of Direct Damages subject to statutory limits;
d. Attorney Fees to the prevailing Party.

7. RISK ALLOCATION

7.1 Indemnification (Authorization Scope)

Recipient shall indemnify, defend, and hold harmless CE and its affiliates from third-party claims 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, aggregate liability shall not exceed the statutory damages or penalties authorized by HIPAA, 42 U.S.C. § 1320d-5, the PA Confidentiality Laws, and related regulations. In no event shall any Party be liable for incidental, consequential, or punitive damages, except as expressly permitted by 35 P.S. § 7610 (HIV Act civil remedies).

7.3 Force Majeure

No Party shall be liable for delay or failure to perform due to events beyond reasonable control, provided prompt notice is given and performance resumes as soon as practicable.

8. DISPUTE RESOLUTION

8.1 Governing Law

This Authorization shall be governed by HIPAA and, to the extent not pre-empted, the laws of the Commonwealth of Pennsylvania, including the PA Confidentiality Laws.

8.2 Forum Selection

The Parties consent to exclusive jurisdiction and venue in the state and federal courts located in [COUNTY, PENNSYLVANIA].

8.3 Optional Arbitration

By mutual written election after a dispute arises, the Parties may submit the matter to binding arbitration under the AAA Healthcare Payor Provider Rules.

8.4 Jury Trial

Nothing herein shall be construed to waive any Party's constitutional right to a jury trial.

9. GENERAL PROVISIONS

9.1 Amendment & Waiver

Any amendment must be in writing and signed by all Parties.

9.2 Assignment

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

9.3 Severability

If any provision is held invalid, it shall be reformed to the minimum extent necessary; the remainder continues in full force.

9.4 Integration

This Authorization constitutes the entire agreement among the Parties.

9.5 Counterparts & Electronic Signatures

Counterparts permitted; electronic signatures equivalent to handwritten signatures.

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:
Authority/Relationship: _____________________

Covered Entity

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

Recipient

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

NOTICE TO INDIVIDUAL (Pennsylvania)

• You have the right to revoke this Authorization in writing at any time, except to the extent action has been taken in reliance on it.
• You have the right to receive a copy of this signed Authorization.
• Treatment, payment, enrollment, or eligibility for benefits cannot be conditioned on signing this Authorization (with limited exceptions).
• Information released may be subject to re-disclosure and may no longer be protected by federal or Pennsylvania law.
• Mental health, HIV, substance use disorder, and genetic information receive heightened protection under Pennsylvania law and require specific written consent (initials above).

SOURCES AND REFERENCES

• 45 C.F.R. § 164.508 — HIPAA Authorization Required Elements
• 50 P.S. § 7111 — Pennsylvania Mental Health Procedures Act, Confidentiality of Records
• 35 P.S. §§ 7601–7612 — Confidentiality of HIV-Related Information Act (esp. § 7607)
• 71 P.S. § 1690.108 — Pennsylvania Drug and Alcohol Abuse Control Act, Confidentiality
• 42 C.F.R. Part 2 — Federal Confidentiality of Substance Use Disorder Patient Records
• 28 Pa. Code § 115.27 — Hospital Records
• 40 P.S. § 908-3 — Genetic Information Restrictions
• 55 Pa. Code Chapter 5100 — Mental Health Procedures (Confidentiality Regulations)