The Health Insurance Portability and Accountability Act of 1996 (HIPAA) restricts the use or disclosure of protected health information (PHI) other than treatment, payment or healthcare operations (TPO). Others that are permitted to receive disclosure of information by law include: Judicial proceedings, coroners, medical examiners, research purposes, law enforcement, worker’s compensation and other areas so designated by law.
Release or disclosure of information to family members, friends, clergy or others involved in a patient’s care is NOT included in the General Rule and require specific authorization for disclosure of information.
If you would like us to share your PHI with family members or others, please fill in the information below for each individual, designate if unrestricted or limited release of information and date and initial each authorization. Please note that ABSOLUTELY NO INFORMATION WILL BE DISCLOSED to spouses, children, other family members, care givers or friends if not authorized below. You may rescind or change any authorization by a written request at any time.