Medical Records Authorization (HIPAA)

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (HIPAA) — DELAWARE

This Authorization for Release of Protected Health Information (this "Authorization") is executed under the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations at 45 C.F.R. Parts 160 and 164 (collectively, "HIPAA"), and, to the extent not preempted, the laws of the State of Delaware.

1. PATIENT IDENTIFICATION

2. PROVIDER(S) AUTHORIZED TO RELEASE INFORMATION

I authorize the following health-care provider(s), facility(ies), hospital(s), clinic(s), pharmacy(ies), laboratory(ies), and health plan(s) (each a "Covered Entity") to release my Protected Health Information ("PHI") as described below:

3. RECIPIENT(S) AUTHORIZED TO RECEIVE INFORMATION

I authorize disclosure of the PHI described below to:

4. SPECIFIC RECORDS AND DATE RANGE

Date range of records requested: From [__/__/____] to [__/__/____], or ☐ all dates of service.

Mark each record type to be released:

☐ All PHI in the patient's designated record set
☐ Office / progress notes and chart
☐ Hospital / facility records (admission, discharge summaries)
☐ History and physical / consultation reports
☐ Operative and procedure reports
☐ Laboratory and pathology results
☐ Diagnostic imaging reports and films (X-ray, MRI, CT, ultrasound)
☐ Emergency department / ambulance / EMS records
☐ Physical therapy / rehabilitation records
☐ Pharmacy and medication records
☐ Billing statements and itemized charges
☐ Other: [________________________________]

5. PURPOSE OF DISCLOSURE

The PHI is disclosed for the following purpose: [DESCRIBE — e.g., "evaluation, investigation, and prosecution of the patient's personal-injury claim," "at the request of the patient," or "legal representation in Civil Action No. ____"].

6. HIPAA REQUIRED STATEMENTS (45 C.F.R. § 164.508(c))

6.1 Expiration. This Authorization expires on the earliest of: (a) [__/__/____]; (b) the event of [________________________________]; or (c) if no date or event is stated, the final resolution of the personal-injury matter described in Section 5, or two (2) years after the date of signature, whichever occurs first.

6.2 Right to Revoke. I may revoke this Authorization at any time by delivering a written revocation to the Covered Entity's privacy officer at the address in Section 2. Revocation will not affect any action the Covered Entity took in reliance on this Authorization before it received the written revocation.

6.3 No Conditioning of Treatment. The Covered Entity may not condition treatment, payment, enrollment in a health plan, or eligibility for benefits on whether I sign this Authorization, except as permitted by 45 C.F.R. § 164.508(b)(4).

6.4 Redisclosure Notice. I understand that PHI disclosed under this Authorization may be redisclosed by the recipient and may then no longer be protected by HIPAA or Delaware law. Information protected by 42 C.F.R. Part 2 (substance-use-disorder records) and by 16 Del. C. § 717 (HIV-related test results) remains subject to redisclosure restrictions, as noted in Section 7.

6.5 Copy of Authorization. I am entitled to a copy of this signed Authorization.

7. SPECIFICALLY PROTECTED CATEGORIES — SEPARATE AUTHORIZATION REQUIRED

I specifically authorize release of the following heightened-consent categories only where I have initialed:

Part 2 warning: Initialing this general authorization does not itself create a consent that satisfies 42 C.F.R. § 2.31. Use a standalone consent containing every applicable current § 2.31 element. If the records will be used or disclosed in a civil, criminal, administrative, or legislative investigation or proceeding, § 2.31(d) prohibits combining that consent with a consent for any other purpose. Each disclosure made under a valid consent must also carry one of the notices permitted by § 2.32(a) and a copy of the consent or a clear explanation of its scope under § 2.32(b).

HIV Notice (16 Del. C. § 717): Delaware law prohibits any person who receives HIV-related test results from redisclosing them except as authorized by 16 Del. C. § 717.

8. DELAWARE COPY-FEE AND RESPONSE-TIME NOTE

Under 24 Del. C. § 1761 and the Board of Medical Licensure & Discipline fee schedule (24 Del. Admin. Code § 1700-16.0, effective Nov. 11, 2009), a provider may charge the reasonable expenses of copying records according to the Board schedule, currently: $2.00 per page for pages 1-10; $1.00 per page for pages 11-20; $0.90 per page for pages 21-60; and $0.50 per page for pages 61 and above, plus the actual cost of postage/shipping and the cost of reproducing records that cannot be photocopied (e.g., radiology films). Payment may be required in advance, except for records related to an application for a disability-benefits program.

9. SIGNATURE AND PERSONAL-REPRESENTATIVE AUTHORITY

I have read and understand this Authorization. I am the patient or the patient's authorized personal representative, and I sign voluntarily.

If signed by a personal representative:

10. NOTARY (OPTIONAL)

State of Delaware, County of [________________________________]

Subscribed and sworn to before me this [____] day of [____________], 20[____].

______________________________
Notary Public
My commission expires: [__/__/____]

SOURCES AND REFERENCES

• 45 C.F.R. § 164.508 — HIPAA Authorization core elements: https://www.ecfr.gov/current/title-45/section-164.508
• 45 C.F.R. § 164.524 — Individual right of access (fees, 30-day response): https://www.ecfr.gov/current/title-45/section-164.524
• 42 C.F.R. Part 2 — Confidentiality of SUD patient records: https://www.ecfr.gov/current/title-42/part-2
• 24 Del. C. § 1761 — Patient access to records; copy-fee schedule: https://delcode.delaware.gov/title24/c017/sc05/
• Delaware Division of Professional Regulation — Medical Records Fees: https://dpr.delaware.gov/boards/medicalpractice/record_fees/
• 16 Del. C. § 717 — Confidentiality of HIV test results: https://law.justia.com/codes/delaware/title-16/chapter-7/subchapter-ii/section-717/
• 16 Del. C. § 5161 — Rights of patients in mental-health facilities
• 16 Del. C. §§ 1201-1204 — Genetic information consent
• 16 Del. C. § 2220 — Substance-abuse treatment records