Authorization Elements

Does the Authorization contain the following core elements?

 

  • Description of the information to be used or disclosed that identifies the information in a specific and meaningful fashion. (Psychotherapy notes require a separate release)
  • Name or other specific identification of the person(s), or class of persons, authorized to make the requested use or disclosure.
  • Name or other specific identification of the person(s), or class of persons, to whom the covered entity may make the requested use or disclosure.

                        

  • Description of each purpose of the requested use or disclosure. The statement “at the request of the individual" is sufficient description of the purpose when an individual initiates the authorization and does not, or elects not to, provide a statement of the purpose.
  • Expiration date or an expiration event that relates to the individual or the purpose of the use or disclosure.

                     

  • Signature of the individual and date. If the authorization is signed by a personal representative of the individual, a description of such representative's authority to act for the individual must also be provided.

               

Does the Authorization contain the following required statements?    

 

  • The individual's right to revoke the authorization in writing, and either: a) The exceptions to the right to revoke and a description of how the individual may revoke the authorization; or b) To the extent that the information is included in the notice of privacy practices.

                      

  • The ability or inability to condition treatment, payment, enrollment or eligibility for benefits on the authorization, by stating either: a) The covered entity may not condition treatment, payment, enrollment or eligibility for benefits on whether the individual signs the authorization when the prohibition on conditioning of authorizations applies; or b) The consequences to the individual of a refusal to sign the authorization when the covered entity can condition treatment, enrollment in the health plan, or eligibility for benefits on failure to obtain such authorization.

                        

  • The potential for information disclosed pursuant to the authorization to be subject to redisclosure by the recipient and no longer be protected.

                  

Other requirements for a valid authorization

    

  • Is the authorization written in plain language?

 

  • Has the expiration date passed or has the expiration event occurred?

               

  • Is the authorization filled out completely?

                         

  • Has the authorization been revoked?

 

  • Is any material information in the authorization known to be false?