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Share Medical Information Form for the United States

Share Medical Information Form Template for United States

A Share Medical Information Form is a legal document compliant with HIPAA regulations in the United States that authorizes the release of an individual's protected health information. This document enables healthcare providers to share specified medical records with designated recipients while maintaining compliance with federal and state privacy laws. It includes specific provisions for the type of information to be shared, duration of authorization, and rights of the patient regarding the sharing of their medical information.

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Share Medical Information Form

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What is a Share Medical Information Form?

The Share Medical Information Form serves as a crucial document in the U.S. healthcare system, ensuring compliance with HIPAA regulations while facilitating the necessary sharing of medical information. This form is required whenever protected health information needs to be shared with parties other than those directly involved in a patient's care or billing. It provides legal protection for healthcare providers and ensures patient privacy rights are maintained. The form must include specific elements required by federal law, including clear identification of the information to be shared, who can share it, who can receive it, and how long the authorization remains valid.

What sections should be included in a Share Medical Information Form?

1. Patient Information: Full legal name, date of birth, address, and contact information of the patient

2. Healthcare Provider Information: Details of the provider/facility authorized to release information

3. Recipient Information: Details of person/entity authorized to receive the medical information

4. Information to be Released: Specific description of medical information authorized for release

5. Duration: Expiration date or event for the authorization

6. Rights Statement: Statement of right to revoke and how to do so

7. Signatures: Patient or legal representative signature, date, and relationship if not patient

What sections are optional to include in a Share Medical Information Form?

1. Specific Authorization: Additional authorization section for specially protected information such as HIV status, mental health records, or substance abuse treatment records

2. Purpose of Disclosure: Optional section specifying the reason for releasing medical information

3. Electronic Delivery Authorization: Additional section authorizing electronic transmission of medical records

What schedules should be included in a Share Medical Information Form?

1. State-Specific Addendum: Additional provisions required by specific state laws

2. Fee Schedule: Schedule detailing any applicable costs associated with records release

3. Instructions: Detailed instructions for completing and submitting the form

Authors

Alex Denne

Head of Growth (Open Source Law) @ ¶¶Òõ¶ÌÊÓÆµ | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

Jurisdiction

United States

Cost

Free to use
Clauses




















Industries

HIPAA 1996: Health Insurance Portability and Accountability Act - Primary federal law governing medical information privacy and security in the United States

HITECH Act 2009: Health Information Technology for Economic and Clinical Health Act - Strengthens HIPAA privacy and security protections and enforcement

HIPAA Privacy Rule: Federal regulations that establish national standards for the protection of individuals' medical records and other personal health information

HIPAA Security Rule: Sets national standards for securing electronic protected health information

Breach Notification Rule: Requires covered entities to notify individuals, HHS, and in some cases the media, of a breach of unsecured protected health information

State Privacy Laws: State-specific regulations that may impose additional or more stringent requirements than federal laws for medical information sharing

42 CFR Part 2: Federal regulations governing confidentiality of substance use disorder patient records

GINA: Genetic Information Nondiscrimination Act - Prohibits discrimination based on genetic information in health insurance and employment

State Minor Consent Laws: State-specific regulations governing consent requirements for sharing medical information of minors

State HIV/AIDS Privacy Laws: Special state-level protections for HIV/AIDS-related medical information

Mental Health Privacy Laws: State and federal regulations providing additional privacy protections for mental health records

Teams

Employer, Employee, Start Date, Job Title, Department, Location, Probationary Period, Notice Period, Salary, Overtime, Vacation Pay, Statutory Holidays, Benefits, Bonus, Expenses, Working Hours, Rest Breaks,  Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination,  Severance Pay, Governing Law, Entire Agreemen

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