HIPAA Authorization Form - Tennessee

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JURISDICTION: TN
LAST UPDATED: 2026-05-11
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HIPAA AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION (TENNESSEE)

(Comprehensive — HIPAA + Tennessee mental health, HIV/STD, substance use, hospital records, and genetic information laws)

TABLE OF CONTENTS

1. Parties and Document Header
2. Definitions
3. Description of PHI and Authorized Disclosure
4. Special Categories of Sensitive Information (TN-Specific)
5. Purpose, Recipients, and Expiration
6. Patient Rights — Revocation, Refusal, Re-Disclosure
7. Representations and Acknowledgments
8. General Provisions
9. Execution Block

1. PARTIES AND DOCUMENT HEADER

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

This Authorization is executed pursuant to 45 C.F.R. § 164.508 and the laws of the State of Tennessee, including T.C.A. §§ 33-3-103 through 33-3-114, T.C.A. § 33-10-408, T.C.A. § 68-10-113, T.C.A. § 68-11-1502, and T.C.A. § 63-2-101.

2. DEFINITIONS

"Authorization" means this HIPAA authorization form, including all schedules and addenda.

"Covered Entity" or "CE" has the meaning given in 45 C.F.R. § 160.103.

"HIPAA" means 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" means the subject of the PHI and the signatory hereto, as defined in 45 C.F.R. § 160.103.

"PHI" means Protected Health Information as defined in 45 C.F.R. § 160.103.

"Service Recipient" has the meaning given in T.C.A. § 33-1-101 for purposes of records covered by Title 33.

"STD Records" means records relating to known or suspected cases of sexually transmitted disease (including HIV/AIDS) within the meaning of T.C.A. § 68-10-113.

"Substance Use Records" means records subject to 42 C.F.R. Part 2 and/or T.C.A. § 33-10-408.

3. DESCRIPTION OF PHI AND AUTHORIZED DISCLOSURE

3.1 Description of PHI to be Used or Disclosed. The following specific and meaningful description of PHI is authorized for Use and/or Disclosure (45 C.F.R. § 164.508(c)(1)(i)):

[Describe records with reasonable specificity — e.g., "All medical records from [DATE] through [DATE]," "Discharge summaries from [Hospital]," "Laboratory results dated [____]," "Imaging studies," "Physician progress notes."]

3.2 Date Range. Records dated from [__/__/____] to [__/__/____], or ☐ all dates on file.

3.3 Form of Disclosure. Disclosure shall be made by:
☐ Paper copy
☐ Electronic copy (PDF / EHR portal)
☐ Certified copy
☐ Facsimile to: [_______________________]
☐ Other: [_______________________]

4. SPECIAL CATEGORIES OF SENSITIVE INFORMATION (TENNESSEE-SPECIFIC)

I specifically authorize the disclosure of the following categories of records (initial each that applies):

4.1 Re-Disclosure of 42 C.F.R. Part 2 Records. Federal law (42 C.F.R. Part 2) prohibits any further re-disclosure of substance use disorder records unless: (a) the Individual signs a separate written consent expressly permitting re-disclosure, (b) re-disclosure is otherwise expressly permitted by 42 C.F.R. Part 2, or (c) re-disclosure is required by law. A general HIPAA authorization is NOT sufficient.

4.2 Re-Disclosure Notice — TN STD/HIV. Information disclosed under T.C.A. § 68-10-113 remains subject to the confidentiality requirements of that statute and applicable federal law.

5. PURPOSE, RECIPIENTS, AND EXPIRATION

5.1 Purpose of Disclosure (45 C.F.R. § 164.508(c)(1)(iv)):
☐ Continuity of care / treatment by new provider
☐ Personal use by the Individual ("at the request of the individual")
☐ Insurance / payment / claims
☐ Legal proceeding — Case No. [_______________________]
☐ Disability / SSA / VA benefits
☐ Workers' compensation
☐ Research study: [_______________________]
☐ Other: [_______________________]

5.2 Authorized Recipient(s) (45 C.F.R. § 164.508(c)(1)(iii)):
Name: [_______________________]
Address: [_______________________]
Phone / Fax / Email: [_______________________]

5.3 Expiration (45 C.F.R. § 164.508(c)(1)(v)). This Authorization expires on the EARLIEST of:
(a) Date: [__/__/____]; or
(b) Event: [e.g., "conclusion of legal proceeding," "completion of research study," "termination of insurance claim"]; or
(c) Written revocation by the Individual under Section 6.1.

If left blank, this Authorization expires one (1) year from the Effective Date.

6. PATIENT RIGHTS — REVOCATION, REFUSAL, RE-DISCLOSURE

6.1 Right to Revoke (45 C.F.R. § 164.508(c)(2)(i)). I may revoke this Authorization at any time by submitting a signed written revocation to:
[Covered Entity HIPAA Privacy Officer Name / Address]

Revocation is effective upon receipt, EXCEPT to the extent the Covered Entity has already acted in reliance on this Authorization before receiving the revocation.

6.2 Refusal Does Not Affect Treatment (45 C.F.R. § 164.508(c)(2)(ii)). The Covered Entity may NOT condition treatment, payment, enrollment in a health plan, or eligibility for benefits on my signing this Authorization, except as permitted under 45 C.F.R. § 164.508(b)(4) (research-related treatment or eligibility for enrollment).

6.3 Re-Disclosure Warning (45 C.F.R. § 164.508(c)(2)(iii)). I understand that information disclosed pursuant to this Authorization may be re-disclosed by the recipient and may no longer be protected by HIPAA. However, records subject to 42 C.F.R. Part 2 and T.C.A. § 68-10-113 retain their statutory protection against re-disclosure.

6.4 Right to Copy. I am entitled to receive a copy of this signed Authorization (45 C.F.R. § 164.508(c)(4)).

6.5 Right to Inspect / Copy Records. Tennessee law (T.C.A. § 63-2-101) and HIPAA (45 C.F.R. § 164.524) provide me with the right to inspect and obtain copies of my own medical records, subject to limited exceptions.

7. REPRESENTATIONS AND ACKNOWLEDGMENTS

7.1 Capacity. I represent that I am the Individual identified above, or the legally authorized personal representative of that Individual under T.C.A. § 33-3-104 or other applicable law, with full authority to execute this Authorization.

7.2 Voluntary. I have read and understand this Authorization. I sign it freely and voluntarily, without coercion.

7.3 Compensation. ☐ I have / ☐ I have NOT received remuneration in exchange for executing this Authorization. (If marketing or sale of PHI is involved, additional disclosures are required under 45 C.F.R. § 164.508(a)(3)-(4).)

7.4 Stringent Tennessee Law Acknowledged. I understand that Tennessee mental health, STD/HIV, and substance use records are subject to confidentiality protections more stringent than HIPAA, and that those protections continue to apply.

8. GENERAL PROVISIONS

8.1 Governing Law. This Authorization is governed by HIPAA and, to the extent not preempted, the laws of the State of Tennessee.

8.2 Severability. If any provision is held invalid, the remaining provisions remain in full force.

8.3 Counterparts and Electronic Signatures. Executed counterparts and electronic signatures (E-SIGN, T.C.A. § 47-10-101 et seq. — Tennessee UETA) are deemed originals.

8.4 Form Compliance. This form is intended to satisfy the core elements of 45 C.F.R. § 164.508(c). Specific recipients may require supplemental forms (e.g., separate § 42 C.F.R. Part 2 consent).

9. EXECUTION BLOCK

IN WITNESS WHEREOF, the Individual (or personal representative) executes this Authorization as of the Effective Date.

Individual / Patient

Signature: _________________________________
Printed Name: _____________________________
Date: __________________

Personal Representative (if applicable)

Signature: _________________________________
Printed Name: _____________________________
Authority / Relationship: _____________________ (e.g., parent of minor; conservator under T.C.A. § 34-3-101 et seq.; attorney-in-fact under T.C.A. § 34-6-201 et seq.; T.C.A. § 33-3-104)
Date: __________________

Witness (recommended for mental health / substance use authorizations)

Signature: _________________________________
Printed Name: _____________________________
Date: __________________

Covered Entity Acknowledgment (optional)

By: __________________________ Title: ____________________
Printed Name: _____________________________
Date: __________________

Sources and References

• 45 C.F.R. § 164.508 — HIPAA authorization core elements
• 45 C.F.R. § 164.508(a)(2) — Psychotherapy notes
• 42 C.F.R. Part 2 — Federal substance use disorder confidentiality
• T.C.A. § 33-3-103 — Confidentiality of mental health records
• T.C.A. § 33-3-104, § 33-3-105 — Disclosure rules
• T.C.A. § 33-10-408 — Alcohol/drug treatment confidentiality
• T.C.A. § 68-10-113 — STD/HIV records confidentiality
• T.C.A. § 68-11-1502 — Patient's Privacy Protection Act
• T.C.A. § 68-11-304 — Hospital records confidentiality
• T.C.A. § 63-2-101 — Patient access to records
• Tennessee Courts — HIPAA & State Laws Quick Reference: https://tncourts.gov/sites/default/files/docs/hippa_-confidentiality_and_state_laws-_quick-reference_list.pdf