Medical Records Authorization (HIPAA) - Kentucky

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (KENTUCKY)

This Authorization complies with the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), 45 C.F.R. § 164.508, and applicable Kentucky law.

1. PATIENT IDENTIFICATION

2. PROVIDER(S) AUTHORIZED TO RELEASE RECORDS

I authorize the following provider(s), facility(ies), and their business associates to release my protected health information ("PHI"):

3. RECIPIENT(S) — WHO MAY RECEIVE THE RECORDS

4. RECORDS / INFORMATION TO BE RELEASED

☐ Complete medical record
☐ Only records for the following date range: [__/__/____] to [__/__/____]
☐ Only records relating to the following incident/condition: [________________________________]

Record types (check all that apply):

☐ History and physical / office notes
☐ Physician and nursing notes
☐ Hospital / emergency-department records
☐ Diagnostic imaging (X-ray, MRI, CT) and reports
☐ Laboratory and pathology results
☐ Operative and procedure reports
☐ Physical therapy / rehabilitation records
☐ Prescription and medication records
☐ Itemized billing statements and insurance records
☐ Other: [________________________________]

5. PURPOSE OF DISCLOSURE

This disclosure is made at the request of the patient for the following purpose: evaluation, investigation, prosecution, and settlement of the patient's personal-injury claim, including legal representation.

☐ Other purpose: [________________________________]

6. HIPAA CORE-ELEMENT RECITALS

6.1 Expiration. This Authorization expires on the earlier of: (a) [__/__/____]; (b) the following event: [final resolution of the personal-injury claim]; or (c) if no date or event is stated, two (2) years from the date of signature.

6.2 Right to Revoke. I may revoke this Authorization at any time by written, signed notice to the provider, except to the extent action has already been taken in reliance on it.

6.3 No Conditioning. Treatment, payment, enrollment, or eligibility for benefits may not be conditioned on whether I sign this Authorization, except as permitted by 45 C.F.R. § 164.508(b)(4).

6.4 Redisclosure Notice. Information disclosed under this Authorization may be redisclosed by the recipient and may then no longer be protected by HIPAA or Kentucky law.

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

7. SPECIAL-CATEGORY RECORDS — SEPARATE SPECIFIC AUTHORIZATION REQUIRED

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).

8. COPY FEES AND RESPONSE TIME (KENTUCKY)

Under KRS 422.317, upon a patient's written request a hospital licensed under KRS Chapter 216B or a health care provider must provide, without charge to the patient, one (1) copy of the patient's medical record. A copying fee not to exceed $1.00 per page may be charged for a second copy requested by the patient, the patient's attorney, or the patient's authorized representative. Patient access rights are also addressed in KRS 216B.0441. KRS 422.317 does not set a fixed deadline; HIPAA's access timeline (generally 30 days, with one 30-day extension under 45 C.F.R. § 164.524(b)) provides the federal floor. Mental-health (KRS 210.235), HIV (KRS 214.181), and SUD (42 C.F.R. Part 2) records require separate authorization.

9. SIGNATURE

Personal representative (if patient is a minor, incapacitated, or deceased):

10. NOTARY (OPTIONAL)

Commonwealth of Kentucky, County of [________________]

Subscribed and sworn 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
• 42 C.F.R. Part 2 — Confidentiality of SUD patient records: https://www.ecfr.gov/current/title-42/part-2
• KRS 422.317 — One free copy of patient's medical record: https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=18145
• KRS 216B.0441 — Patient rights; access to records: https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=53442
• KRS 210.235 — Confidentiality of mental health records: https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=43271
• KRS 214.181 — HIV testing; confidentiality: https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=43352