HIPAA Forms for use by Florida lawyers

 

The following HIPAA forms are recommended by The Florida Bar Health Law Section

HIPAA Committee for use by the bar in Florida as being consistent with Federal HIPAA

privacy and confidentiality rules found at 45 CFR 160, et. seq.

 

As is the case when using forms, they do not constitute legal advice. Consult competent

counsel before using them.

 

TAL:45017:1

Approved September 24, 2003

Florida Bar Health Law HIPAA

Committee

AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

UNDER HIPAA RULE 164.508

You May Refuse to Sign This Authorization

I, _____________________________, (hereafter referred to as “Individual”) hereby authorize

_______________________________________________, (hereafter collectively referred to as “you”) to

use and disclose in any form or format a copy of records concerning Individual but only as follows, to:

_____________________________________________________________________for the purpose(s) of

(be specific): _____________________________________________I specifically authorize you to use

and disclose the following types of super-confidential information (initial where appropriate):

___ HIV records (including HIV test results) and sexually transmissible diseases

___ Alcohol and substance abuse diagnosis and treatment records

___ Psychotherapy records

___ Tuberculosis

___ All hospital records

___ All of the above

I specifically authorize you to use and disclose the following Protected Health Information. Please initial

one or more of the following, if applicable:

Written Medical records

___ X-rays/MRI/CT

___ Billing records

___ Prescription records

Other (specify in detail)_______________________________________________________

___ All of the above

I understand that my records may be subject to re-disclosure by recipient(s) and unprotected by federal or

state law; that this Authorization remains effective until the following date: ___________________; the

following event: __________________________________; or until you actually receive a signed

revocation or until the records retention period required under federal and Florida law has expired,

whichever first occurs; that I have been given an opportunity to ask questions; that I have received a copy

of the signed Authorization; that I may inspect a copy of my protected health information to be used or

disclosed under this Authorization; that you have not conditioned provision of services to or treatment of

me upon receipt of this signed Authorization; and that I may refuse to sign this Authorization. My refusal

to sign will not affect my eligibility for benefits or enrollment, payment for or coverage of services, or

ability to obtain treatment, except as provided on this form. If the purpose of this Authorization is for the

use and/or disclosure of health information for a research study, and I refuse to sign this Authorization, you

reserve the right to deny treatment associated with such research. If the purpose of this Authorization is to

disclose health information to another party based on health care that is provided solely to obtain such

information, and I refuse to sign this Authorization, you reserve the right to deny that health care. I

understand that I may inspect or copy the information that is used or disclosed. I understand that I may

revoke this Authorization at any time by notifying you in writing, except to the extent that action has been

taken in reliance on this Authorization; or if this Authorization is obtained as a condition of obtaining

insurance coverage, other law provides the insurer with the right to contest a claim under the policy or the

policy itself.

A copy of this signed form will be provided the individual.

By Patient:___________________________________________________Date: _____________

(Print name and sign)

Or

By Patient's Representative:_____________________________________Date:______________

(Print name, sign, and describe authority below)

___________________________________________

___________________________________

TAL:45017:1

2

Approved September 24, 2003

Florida Bar Health Law HIPAA Committee

ACKNOWLEDGMENT OF RECEIPT HIPAA PRIVACY NOTICE

UNDER HIPAA RULE 164.520

You May Refuse to Sign This Acknowledgment

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices of

_____________ this ___ day of ________, 20__.

____________________

Please print your name

____________________

Please sign your name

If you are the legal representative of the patient, please print the patient’s name(s) and describe your authority

_____________________________________________.

Thank you and if you have any questions about this form or the attached Notice, please contact Privacy Officer,

________, ___________________.

--------------------------------------------------------------------------------------------------------------------

___________________ USE ONLY

I attempted to obtain the patient’s (or representative’s) signature on this Acknowledgment but did not because:

It was emergency treatment

____

I could not communicate with the patient

____

The patient refused to sign

____

The patient was unable to sign because

____

Other (please describe)

____

__________________________________________________________________________

____________________________________ ________________

Signature Date

____________________________________

Signature of other witness, if any

TAL:45017:1

3

Approved September 24, 2003

Florida Bar Health Law HIPAA Committee

REQUEST TO INSPECT, COPY OR SUMMARIZE UNDER HIPAA RULE 164.524

Return completed form to Privacy Officer, ________, ___________________:

Please note that we may deny your request to inspect, copy or summarize records if you are not the patient or

the patient’s legal representative, if we do not have the records, or in other circumstances. If we deny your

request, you may ask us to review that decision.

COMPLETE AS APPLICABLE:

1. This request pertains to the records of _______________________________________________________.

2. I want to inspect the entire medical record (including clinical and billing information) ____ or I want to inspect

only the following type of records:________________________________________________________

• I wish to inspect the records from ___ am/pm to ___ am/pm on ____, ______, 20__.

• I will bring with me the following persons: __________ and I hereby authorize ___________________ to

disclose and otherwise provide them with full and complete access to the records described above.

• I agree that original records will not leave the premises and that ___________________’s privacy officer

will be present at all times during the inspection. _____ yes _____ no.

3. I want a copy of the entire medical record ____ or only the following records_______________________:

• I want photocopies ___ other format:_______________________________.

• The copy will be ready for pick-up at ____, on _____, ___.

• I acknowledge I will pay costs in the amount of ________ before the copies are released.

4. I want a SUMMARY of the entire medical record ___ or only the following records: __________________

• The summary will be ready for pick-up at ____ on ___.

• I acknowledge I will pay costs in the amount of ____________ before the summary is released.

By Patient:_____________________________________

Date:___________

(Print name and sign)

Or

By Patient's Representative________________________

Date: ____________

(Print name, sign, and describe authority)

---------------------------------------------------------------------------------------------------------------------------------------

___________________ USE ONLY

1. Request denied because records were:

Not in our possession (and we advised the patient where they were, if known)

___

From a confidential source that would be revealed if records were disclosed to patient

___

Other (describe): ________________________________________________________________

2. Patient requested a review of the denial on ______________________. We have selected _________________

to review our denial.

3. Upon review of our denial, _____________________’s recommendation was ____________________.

4. Copy of records in format requested not provided because:

Impracticable

___

Patient refused payment of copying charge ___

Patient failed to pick-up

___

Other (describe)

___

__________________________________________________________________________________________

5. Copy of records released to ____________________________ on _______________________.

6. Summary of records released to __________________________ on ________________________.

________________________________ ____________________

TAL:45017:1

4

Privacy Officer Date

Approved September 24, 2003

Florida Bar Health Law HIPAA Committee

RESPONSE TO RECORDS REQUEST

UNDER HIPAA RULE 164.524

Sent to : ______________________________

_____________________________________

Dear: _______________________________

On ______________, you submitted a request to us pertaining to the records of

_____________________________.

COMPLETE AS APPLICABLE:

1. We are ready to prepare the copy ___ summary ____ (check one) you requested.

The cost for this service is $____. Upon receipt of this charge, we will provide the requested records. Please

contact our Privacy Officer, ________, ___________________ to arrange a time to pick-up the records. If you

prefer, we will mail them to you. Please call to determine the additional postage cost and let us know where you

want us to mail the records.

2. We are ready to provide you with access to inspect the records as you requested. Your appointment time is from

_____ am/pm to ___ am/pm on ______________________ at _______________. Please contact our Privacy

Officer at least 24 hours in advance if you will be unable to make this appointment.

3. We are denying all ___ some _____ (as indicated below) of your request because:

___ We do not have the following records: _____________________________________

___ We believe you may obtain the records by contacting:

___ We do not know where you may obtain the records

___ It was impracticable for us to produce the copy or summary in the format you requested. Please

contact our Privacy Officer if you would like paper copies.

___ We cannot give you access to the following records___________________ because:

___

You lack authority under Florida law to access these records (e.g., the patient has not

given you authority in writing, the written authority has been revoked, the records are

super-confidential and you have only a general authority).

___

The information was given to us on a confidential basis and revealing the records

would disclose the source of the information.

___

The information has been compiled in anticipation of litigation.

___

The information is protected by the Clinical Laboratory Improvement Amendments of

1988 (42 U.S.C. §263a) or the Privacy Act (5 U.S.C. §552a).

___

A licensed health care provider has determined, in the exercise of his or her

professional discretion, that disclosing the records would endanger the health or safety

of you or another person.

___

Other: _____________________________________________________

4. If you disagree with our decision, you may file a written complaint with Privacy Officer.

______________________ ______________

Privacy Officer Date

TAL:45017:1

5

Approved September 24, 2003

Florida Bar Health Law HIPAA Committee

REVOCATION OF HIPAA AUTHORIZATION FORM

UNDER HIPAA RULE 164.508

Return completed form to Privacy Officer, ________, ___________________:

_____________________________________________________________________________________

Please be advised that I, the undersigned, do hereby revoke that certain Authorization (describe in detail the

recipient of the records) between the ________, (hereafter ___________________) and

______________________________________________________________________ dated the _____ day of

______________________, 20____.

This revocation will take effect upon actual receipt unless we, our employees, or our agents have already acted

based on the underlying Authorization.

By Patient: _____________________________________

Date: _____________

________________________________________________

(Print name and sign)

Or

By Patient's Representative ________________________

Date: ____________

(Print name, sign, and describe authority)

-----------------------------------------------------------------------------------------------------------------------------

___________________ USE ONLY

Date revocation received: _________________________

_______________________________ _________________

Privacy Officer Date

TAL:45017:1

6

Approved September 24, 2003

Florida Bar Health Law HIPAA Committee

REQUEST TO AMEND PROTECTED HEALTH INFORMATION

UNDER HIPAA RULE 164.526

A.

THE PURPOSE OF THIS REQUEST FORM

Under the Privacy Rules of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you may

request that we amend or correct your protected health information. Accordingly, this form is being made available

to you should you wish to request such an amendment or correction. The HIPAA Privacy Rules allow you to make

such a request, but do not necessarily require us to agree to your request. Note that your request to amend or correct

your records is limited, in most instances, to the records that we created. Please see our Notice of Privacy Practices

for further information.

B.

YOUR REQUESTED AMENDMENT OR CORRECTION

In the space provided below, please describe what amendment or correction to your protected health information

you are requesting. Please be as detailed as possible, and if you have any questions, do not hesitate to seek our

assistance.

C.

THE REASON FOR YOUR REQUEST

In order for us to decide whether we will agree to your requested amendment or correction, please describe the

specific reasons for your request.

D.

OTHER INFORMATION CONCERNING YOUR REQUEST

If you have any questions regarding your request, or the HIPAA Privacy Rules that apply to this request, please

contact our Privacy Officer at ________________________.

Name of Patient (please print)

[Patient identifier here]

Date of birth

________________________________________________

Social Security Number

________________________________________________

Patient’s Signature

OR

Personal Representative (please print)

Personal Representative Signature:

Date:

TAL:45017:1

7

Approved September 24, 2003

Florida Bar Health Law HIPAA Committee

REQUEST TO RESTRICT USES AND DISCLOSURES

OF PROTECTED HEALTH INFORMATION UNDER HIPAA RULE 164.522

A.

THE PURPOSE OF THIS REQUEST FORM

Under the Privacy Rules of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you may

request us to restrict the use and disclosure of your protected health information. Accordingly, this form is being

made available to you should you wish to request such a restriction. The HIPAA Privacy Rules allow you to make

such a request, but do not require us to agree to your request. Please see our Notice of Privacy Practices for further

information.

B.

YOUR REQUESTED RESTRICTION

In the space provided below, please describe what restrictions on the use and/or disclosure of your protected health

information you are requesting. Please be as detailed as possible, and if you have any questions, do not hesitate to

seek our assistance.

C.

OTHER INFORMATION CONCERNING YOUR REQUEST

This request is governed by the HIPAA Privacy Rules. Even if we agree to your requested restriction, that

agreement will not prevent us from making uses or disclosures as otherwise permitted or required under the HIPAA

Privacy Rules or our Notice of Privacy Practices. Also, if our Privacy Officer agrees to your requested restriction,

we may later terminate that agreement by informing you of that termination.

If you have any questions regarding your request, the HIPAA Privacy Rules, or our Notice of Privacy Practices that

apply to this request, please contact our Privacy Officer at: ____________.

Name of Patient (please print)

[Patient Identifier]

Date of Birth

________________________________________________

Social Security Number

________________________________________________

Patient’s Signature

OR

Personal Representative (please print)

Personal Representative Signature:

Date:

TAL:45017:1

8

Approved September 24, 2003

Florida Bar Health Law HIPAA Committee

REQUEST FOR ACCOUNTING OF DISCLOSURES

UNDER HIPAA RULE 164.528

Return completed form to Privacy Officer, ________, ___________________

Please note that we may deny your request for accounting of disclosures if you are not the patient or the patient’s

legal representative, if the disclosure was made to you or your legal representative, if it was made to others for

treatment, payment or healthcare-operations purposes, or in other circumstances. The first Accounting in any 12-

month period is without charge. Other Accountings within that period may be subject to cost-based fees.

COMPLETE AS APPLICABLE:

1. Please provide me with an accounting of disclosures pertaining to the records of ______________________.

2. Please include disclosures made from _________, _____ to __________, ____.

3. Please provide me with the accounting in the following format: photocopies ___other__________.

4. The accounting will be ready for pick-up at ____, on _____, ___.

5. I acknowledge I will pay costs in the amount of ________ before the accounting will be released.

By Patient: _____________________________________

Date: _____________

(Print name and sign)

Or

By Patient's Representative ________________________

Date: _____________

(Print name, sign, and describe authority)

---------------------------------------------------------------------------------------------------------------------------------------

___________________ USE ONLY

1. Request for accounting denied because:

Disclosures occurred more than six years before the date of the request ____

Disclosures occurred prior to April 14, 2003

____

Patient refused to pay costs

____

Other

____

2. Business Associates instructed to provide ___________________ with an accounting of their disclosures on:

__________________________________________________________________________________________

3. Disclosures released to individual on ___________________________________.

________________________________ _________________

Privacy Officer Date

TAL:45017:1

9

Approved September 24, 2003

Florida Bar Health Law HIPAA Committee

ACCOUNTING OF DISCLOSURES OF

PROTECTED HEALTH INFORMATION UNDER HIPAA RULE 164.528

This is an accounting under the Privacy Rules of the Health Insurance Portability and Accountability Act of 1996

(HIPAA).

I.

INTRODUCTION

Under HIPAA, you have the right, with some exceptions, to receive an accounting of disclosures of protected health

information made by us and our business associates. The first Accounting in any 12-month period is without charge.

Other Accountings within that period may be subject to cost-based fees. The accounting you requested is set forth

below. Please note that the Privacy Rules do not require Accounting for disclosures prior to April 14, 2003.

II.

ACCOUNTING

A.

Our Disclosures

Patient name

Date of disclosure

and by whom

Name and address of

recipient

Protected health

information disclosed

Purpose of disclosure

B.

Business Associates’ Disclosures

Patient name

Date of disclosure

and by whom

Name and address of

recipient

Protected health

information disclosed

Purpose of disclosure

This accounting has been prepared in accordance with the above referenced Privacy Rule and is being furnished to

you in compliance with our obligations under the HIPAA Privacy Rules. If you have any questions regarding this

Accounting, please contact our Privacy Officer at: ______________________.

Name of Covered Entity

By:

Date of Request:

Date of Accounting:

TAL:45017:1

10

Approved September 24, 2003

Florida Bar Health Law HIPAA Committee

REQUEST TO RECEIVE COMMUNICATIONS OF PROTECTED

HEALTH INFORMATION BY ALTERNATIVE MEANS OR AT AN ALTERNATIVE LOCATION UNDER

HIPAA RULE 164.522

I.

INTRODUCTION

Under the HIPAA Privacy Rules, you may request, and we must accommodate, your reasonable request to receive

communications of protected health information by alternative means or at an alternative location. We are providing

you with this form to make such a request.

II.

REQUESTED ALTERNATIVE METHOD OF COMMUNICATION

In the space provided below, please describe what alternative means through which you desire to receive

communications from us (for example, by voice mail or e-mail).

III.

ALTERNATIVE ADDRESS FOR CONTACT

Please state the address of the alternative location or other method of contact that you want us to utilize in

communicating with you.

If you have any questions regarding your request, or the HIPAA Privacy Rules that apply to this request, please

contact our Privacy Officer at: _______________________________________.

Name of Patient (printed)

[Patient Identifier]

________________________________________________

Date of Birth

________________________________________________

Social Security Number ________________________________________________

Patient’s Signature

Or

Personal Representative

Date:

TAL:45017:1

11

Approved September 24, 2003

Florida Bar Health Law HIPAA Committee

COMPLAINT FORM UNDER HIPAA RULE 164.530

Individual’s name: ____________________________________________

Individual’s address: ___________________________________________

Individual’s telephone number: ____________________________________

Individual’s record number: ______________________________________

What is the complaint that you have? ____________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

What documents should we review in considering this complaint?

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

Who else might have information about the complaint?

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

Specify the relief sought:

___________________________________________________________________________________________

We will act on your complaint in a prompt manner and we will advise you of its outcome.

----------------------------------------------------------------------------------------------------------------------------------------

___________________ Use Only:

Name of Staff Member: _________________Title: ________________________________________________

Resolution of complaint:

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Signature of Privacy Contact ___________________________ Date ______________________________

TAL:45017:1

12

Approved September 24, 2003

Florida Bar Health Law HIPAA Committee

CONFIDENTIALITY LOG UNDER HIPAA RULE 164.530

I UNDERSTAND that during the course of my business with __________________ that I may have “incidental”

and inadvertent access to patients’ Protected Health Information. I agree to treat the Protected Health Information

as private and confidential and will not use or disclose that information for any purpose.

Company name

Employee

Signature

Date

Time in

Time out

TAL:45017:1

13

Approved September 24, 2003

Florida Bar Health Law HIPAA Committee

DOCUMENTATION OF EMPLOYEE TRAINING

UNDER HIPAA RULE 164.530

HIPAA requires us to train employees on our health information privacy policies and procedures. All employees

with treatment, payment or health care operations responsibilities, which allow access to protected health

information, are periodically trained. HIPAA also requires that we keep Documentation that the training was

completed for six years after the training.

I, the undersigned, do hereby certify that I have received HIPAA training on the date indicated below:

___________________________

___________________________

___________

Print Name

Signature

Date

This Documentation must be placed in the Employee’s Personnel File.

PRIVACY NOTICE FOR E-MAIL MESSAGES UNDER HIPAA RULE 164.530

This message is not intended to be a legally binding or legally effective electronic signature. The Documents

accompanying this message may contain protected health information (PHI) or other confidential information that

is privileged, proprietary, confidential, or otherwise legally exempt from disclosure. This information is intended

only for the use of the individual or entity named above. The authorized recipient of this information is prohibited

from disclosing this information to any other party and is required to protect the confidentiality of the information

after its stated use has been fulfilled. If this is an e-mail message that contains a forwarded message or is a reply

to a prior message, some or all of the contents of this message or its attachments may not have been produced by

the sender.

If you are not the intended recipient, you are hereby notified that any retention, disclosure, copying, distribution

or action taken in reliance on the contents of these Documents is strictly prohibited. If you have received these

Documents in error, please notify the sender immediately at (insert sender’s phone or fax number, e-mail address,

as applicable) to arrange for their return and delete all copies of this message.

TAL:45017:1

14

Approved September 24, 2003

Florida Bar Health Law HIPAA Committee

PROHIBITION ON RE-DISCLOSURE UNDER HIPAA RULE 164.530

(HIV INFORMATION)

This information has been disclosed to you from records whose confidentiality is protected by Florida law.

Florida law prohibits you from making any further disclosure of such information without the specific written

consent of the person to whom such information pertains, or as otherwise permitted by state law.

PROHIBITION ON RE-DISCLOSURE UNDER HIPAA RULE 164.530

(SUBSTANCE ABUSE / PSYCHOTHERAPY INFORMATION)

This information is confidential under Florida and federal law. Federal regulations (42 CFR §§ 2.1 et seq.)

prohibit any further disclosure without the specific written consent of the person to whom it pertains, or as

otherwise permitted by such regulations.

TAL:45017:1

15

Approved September 24, 2003