HIPAA Authorization Form - West Virginia

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

(Comprehensive — HIPAA and West Virginia Health Care Records Law)

1. DOCUMENT HEADER

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

2. PURPOSE OF AUTHORIZATION

The Patient authorizes the Covered Entity to use and/or disclose the Protected Health Information ("PHI") described below to the Authorized Recipient(s) for the following purpose(s):

☐ Continuity of care / treatment by another provider
☐ Insurance claim, underwriting, or coordination of benefits
☐ Legal proceeding — Civil Action No. [__________], Court: [__________]
☐ Personal records / patient's own request
☐ Disability / Social Security determination
☐ Workers' compensation
☐ Research study: [__________]
☐ Other: [__________]

3. SPECIFIC INFORMATION AUTHORIZED FOR DISCLOSURE

The following categories of records are authorized for release:

☐ Complete medical record
☐ Office / clinic visit notes — date range [__/__/____] to [__/__/____]
☐ Laboratory test results
☐ Diagnostic imaging (X-ray, MRI, CT, ultrasound) and radiology reports
☐ Operative and procedure reports
☐ Hospital discharge summaries and inpatient records
☐ Prescription / medication history
☐ Immunization records
☐ Billing and itemized statements (subject to W. Va. Code Section 16-29-2 fee schedule)
☐ Other: [__________]

4. SPECIAL CATEGORIES — SEPARATE WEST VIRGINIA AUTHORIZATION REQUIRED

If no box is initialed, none of the above categories may be released under this Authorization.

5. EXPIRATION

This Authorization shall expire on the earliest to occur of:

☐ Date certain: [__/__/____]
☐ Event: [e.g., conclusion of litigation, end of treatment course]
☐ One (1) year from the date of signature (default)

6. RIGHT TO REVOKE

The Patient may revoke this Authorization at any time by delivering written notice to:

Privacy Officer, [Covered Entity Name]
[Address] | [Email] | [Fax]

Revocation is effective upon receipt, except to the extent the Covered Entity has already acted in reliance on the Authorization. See 45 C.F.R. Section 164.508(b)(5).

7. RE-DISCLOSURE WARNING

Information disclosed pursuant to this Authorization may be re-disclosed by the Recipient and may no longer be protected by HIPAA or West Virginia law. Records protected by 42 C.F.R. Part 2 (federal substance use disorder confidentiality) carry an additional prohibition on re-disclosure without further written consent. HIV-related test results disclosed under W. Va. Code Section 16-3C-3 remain confidential in the hands of authorized recipients, who may re-disclose only for a permitted purpose or as permitted by law.

8. CONDITIONS ON TREATMENT, PAYMENT, OR ENROLLMENT

The Covered Entity may not condition treatment, payment, enrollment in a health plan, or eligibility for benefits on the execution of this Authorization, except as permitted by 45 C.F.R. Section 164.508(b)(4) (research-related treatment, eligibility determinations by a health plan, or where the PHI is created for disclosure to a third party).

9. PROHIBITION ON SALE OF PHI

No remuneration may be received in exchange for the disclosure of PHI authorized hereunder, except as permitted by 45 C.F.R. Section 164.508(a)(4). This Authorization does not authorize marketing as defined in 45 C.F.R. Section 164.501.

10. PATIENT RIGHTS NOTICE

The Patient acknowledges:

a. The right to inspect and copy the PHI to be disclosed (45 C.F.R. Section 164.524; W. Va. Code Section 16-29-1, requiring the provider to furnish copies within 30 days of a written request);
b. The right to receive a copy of this signed Authorization;
c. That refusal to sign will not affect treatment, payment, enrollment, or benefits eligibility except as permitted by law;
d. The right to revoke this Authorization in writing as set forth in Section 6;
e. The right to enforce W. Va. Code Section 16-29-1, including recovery of attorney fees and costs against a provider that violates the article.

11. SIGNATURE

12. PROVIDER ACKNOWLEDGMENT (OPTIONAL)

Received by:

Signature: _______________________________
Printed Name / Title: [__________________________]
Date: [__/__/____]

SOURCES AND REFERENCES

• 45 C.F.R. Section 164.508 — required elements of a valid HIPAA authorization
• W. Va. Code Section 16-29-1 — Patient Access to Medical Records Act (30-day furnishing requirement)
• W. Va. Code Section 16-29-2 — permissible fees for copies
• W. Va. Code Section 27-3-1 — confidentiality of mental health communications and records
• W. Va. Code Section 16-3C-3 — AIDS-related medical testing and records confidentiality
• W. Va. Code Section 27-1A-12 — substance use disorder treatment records
• 42 C.F.R. Part 2 — federal SUD confidentiality
• W. Va. Code Section 33-44-1 — genetic information in insurance