HIPAA Authorization Form - Wyoming

WYOMING HIPAA AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

(Comprehensive — 45 C.F.R. § 164.508, Wyo. Stat. §§ 35-2-606, 25-10-122, 35-4-130, and 42 C.F.R. Part 2)

1. PATIENT / INDIVIDUAL IDENTIFICATION

2. DISCLOSING PARTY (HOSPITAL / COVERED ENTITY)

Name of Hospital / Health Care Provider: [____________________________]
Address: [____________________________]
Privacy Officer / HIM Department: [____________________________]
Telephone / Fax: [____________________________]

3. RECIPIENT(S) AUTHORIZED TO RECEIVE INFORMATION

4. SPECIFIC INFORMATION TO BE DISCLOSED

Check (☐) each category authorized.

☐ Complete medical record
☐ History and physical examination notes
☐ Discharge summaries
☐ Operative and pathology reports
☐ Laboratory results (non-HIV/STI, non-genetic)
☐ Radiology / diagnostic imaging reports
☐ Consultation reports
☐ Medication / prescription records
☐ Immunization records
☐ Emergency department / urgent care records
☐ Billing and claims records
☐ Other (specify): [____________________________]

Date Range of Records: From [__/__/____] to [__/__/____]

5. SPECIAL-CATEGORY RECORDS — WYOMING-SPECIFIC AUTHORIZATIONS

5.1 Mental Health Records — Wyo. Stat. Ann. § 25-10-122

I specifically authorize disclosure of records and reports made under the Wyoming Title 25 mental health hospitalization act that directly or indirectly identify me as a patient, former patient, or individual for whom an application for directed outpatient commitment or involuntary hospitalization has been filed. I understand that, absent this consent, Wyo. Stat. § 25-10-122 prohibits disclosure except in narrow statutory circumstances (necessity to carry out the act, court order in pending proceedings, or referral/treatment coordination among designated facilities under W.S. § 25-10-104).

Specific records authorized:

☐ Mental health treatment records (outpatient)
☐ Mental health hospitalization records (inpatient)
☐ Records of involuntary hospitalization or directed outpatient commitment proceedings
☐ Psychiatric medication records
☐ Mental health center records

Patient Initials (required for § 25-10-122 records): [____]

5.2 Substance Use Disorder Records — 42 C.F.R. Part 2 (and parallel Wyoming mental health/AODA records under § 25-10-122)

I specifically authorize disclosure of records protected under 42 C.F.R. Part 2 (federal confidentiality of substance use disorder records). I understand the recipient is prohibited from redisclosing these records without my further written consent or a court order meeting Part 2 requirements.

Patient Initials (required for 42 C.F.R. Part 2 records): [____]

5.3 HIV / Sexually Transmitted Infection Records — Wyo. Stat. §§ 35-4-130, 7-1-109

I specifically authorize disclosure of HIV test results and other sexually transmitted infection (STI) records included within the list of reportable diseases established under Wyo. Stat. § 35-4-130(b). I understand that under Wyo. Stat. § 7-1-109(f) STI test results ordered in connection with criminal proceedings are confidential except as permitted by statute, and that Department of Health rules restrict information and records relating to known or suspected STI cases.

Patient Initials (required for HIV / STI results): [____]

5.4 Genetic Information — Wyo. Stat. § 26-1-105 and GINA

I specifically authorize disclosure of genetic test results and genetic information, subject to the limitations of Wyo. Stat. § 26-1-105 (genetic information in insurance) and the federal Genetic Information Nondiscrimination Act (GINA).

Patient Initials (required for genetic information): [____]

5.5 Psychotherapy Notes — 45 C.F.R. § 164.508(a)(2)

I specifically authorize disclosure of psychotherapy notes, which under HIPAA require a separate authorization from other PHI.

Patient Initials (required for psychotherapy notes): [____]

5.6 Reproductive Health Records

☐ Yes — included ☐ No — excluded

Patient Initials (if included): [____]

6. PURPOSE OF DISCLOSURE

Disclosure is requested for the following purpose(s):

☐ Continuity of care / treatment by another provider
☐ Personal use by patient
☐ Legal proceeding — Case No.: [____________________________]
☐ Insurance / disability claim
☐ Social Security / SSI / SSDI determination
☐ Workers' compensation claim
☐ Employment / pre-employment evaluation
☐ Educational placement / IEP
☐ Research study: [____________________________]
☐ At the request of the patient
☐ Other (specify): [____________________________]

7. RIGHT TO REVOKE

I understand that I may revoke this authorization at any time by delivering written notice of revocation to the Privacy Officer / HIM Department identified in Section 2. Revocation is effective on receipt, except to the extent that the Disclosing Party has already acted in reliance on the authorization. Under 42 C.F.R. § 2.31(a)(6) and applicable Wyoming law, revocation does not affect disclosures already made.

8. EXPIRATION

This authorization expires on the earliest of:

(a) Specific date: [__/__/____]
(b) Specific event: [____________________________]
(c) Completion of the purpose stated in Section 6
(d) One (1) year from the date signed, if no other date or event is specified
(e) Written revocation under Section 7

9. REQUIRED HIPAA AND WYOMING NOTICES

9.1 Conditioning of Treatment / Payment / Enrollment / Eligibility. Except as permitted under 45 C.F.R. § 164.508(b)(4), the Disclosing Party may not condition my treatment, payment, enrollment, or eligibility for benefits on whether I sign this authorization.

9.2 Re-Disclosure Warning. Information disclosed under this authorization may be re-disclosed by the recipient and may no longer be protected by HIPAA or Wyoming law. However, records protected under 42 C.F.R. Part 2 and Wyoming mental health records under Wyo. Stat. § 25-10-122 generally may NOT be re-disclosed without further authorization or a court order satisfying applicable law.

9.3 Right to Copy. I am entitled to receive a copy of this signed authorization.

9.4 Right to Inspect. I retain the right to inspect and copy my own records under Wyo. Stat. § 35-2-607 (and § 35-2-611 for hospital records) and 45 C.F.R. § 164.524.

9.5 Hospital Disclosure Log. I acknowledge that the hospital will maintain a record of this disclosure for at least three (3) years as required by Wyo. Stat. § 35-2-606(b), including the recipient's name, address, institutional affiliation, date, and a description of the information disclosed.

9.6 No Sale of PHI / No Marketing. The Disclosing Party will not sell my PHI and will not use it for marketing without separate written authorization.

10. SIGNATURE

I have read this authorization (or had it read to me). I understand its contents. I am signing voluntarily and authorize the use and disclosure of my Protected Health Information as described above.

Patient Signature: _______________________________________
Printed Name: [____________________________]
Date: [__/__/____]

If Signed by Personal Representative

Representative Signature: _______________________________________
Printed Name: [____________________________]
Date: [__/__/____]
Authority (check one):
☐ Parent / legal custodian of minor (see Wyo. Stat. § 25-10-122(a)(i))
☐ Court-appointed guardian (attach Letters of Guardianship)
☐ Health care agent under Wyo. Stat. § 35-22-403 (attach Advance Directive / POA-HC)
☐ Personal representative of decedent's estate (attach Letters)
☐ Other (specify): [____________________________]

Witness (Required if Patient Signs by Mark)

Witness Signature: _______________________________________
Printed Name: [____________________________]
Date: [__/__/____]

11. SOURCES AND REFERENCES

• 45 C.F.R. § 164.508 — HIPAA authorization core elements
• Wyo. Stat. Ann. § 35-2-606 — Disclosure of hospital health care information
• Wyo. Stat. Ann. § 35-2-607 — Patient access
• Wyo. Stat. Ann. § 35-2-609 — Exceptions to authorization
• Wyo. Stat. Ann. § 35-2-611 — Hospital response to record requests
• Wyo. Stat. Ann. § 25-10-122 — Mental health records confidentiality
• Wyo. Stat. Ann. § 35-4-130 — Reportable STIs including HIV
• Wyo. Stat. Ann. § 7-1-109 — STI test results in criminal proceedings (confidentiality)
• Wyo. Stat. Ann. § 26-1-105 — Genetic information in insurance
• 42 C.F.R. Part 2 — Federal SUD records confidentiality