to use and disclose my individually identifiable Protected Health Information (PHI) to Capital Women’s Care in the manner described below.
I understand that I have the right to access1 my complete medical records maintained by Capital Women’s Care, based on the federal HIPAA law. I understand that when I want my records to be sent to Capital Women’s Care, I will be asked to sign this form unless I have provided Capital Women’s Care with a similar HIPAA-compliant form. I also understand that my Protected Health Information (PHI) may be re-disclosed by Capital Women’s Care per my request, and that it then may no longer be protected by federal privacy regulations. The applicable state law may or may not prohibit such re-disclosure by the person or entity receiving my PHI from Capital Women’s Care. I understand that signing this authorization is voluntary and will not condition my treatment, payment, enrollment or eligibility for benefits.
1. GENERAL RELEASE: I would like copies of the following types of Medical Record to be sent:
Please Check ONE:
OR
2. CONFIDENTIAL INFORMATION2 PROTECTED BY STATE/FEDERAL LAW: I would like the following information excluded from the information released:
An individual does not have a right to access PHI that is not part of a designated record set because the information is not used to make decisions about individuals. This may include certain quality assessment or improvement records, patient safety activity records, or business planning, development, and management records that are used for business decisions. In addition, two categories of information are expressly excluded from the right of access: Psychotherapy notes, and information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding. See 45 CFR 164.524(a)(1)(ii).
2 HEALTH-GENERAL ARTICLE § § 4-301--4-309, 8-601
3 A “Designated Record Set” is defined by HIPAA as a group of records maintained by a covered entity that may include patient records, bills, information maintained by medical management record systems, or information used to make care-related decisions.
4 External records include but are not limited to Special Outside Correspondence. Such records are records created by non-Capital Women’s Care providers, sent to Capital Women’s Care, and added into the patient’s electronic health record. This information is supplied to Capital Women’s Care but, per our Designated Record Set policy, it is not included in our Legal Medical Record and shall be supplied to patients only upon request.
I certify that I have read, signed, and received a copy of this authorization upon my request or at the request of a representative legally authorized to make this request on my behalf. I understand that I may be billed for copies of my medical records from the entity sending them to Capital Women’s Care according to applicable state and federal laws and guidelines. I understand that I have the right to receive a copy of this authorization. I also understand this authorization is valid for ninety (90) days only and may be revoked in writing at any time prior by notifying the entity releasing information in writing. I understand I have the right to revoke the authorization at any time except to the extent that action has been taken in reliance thereon.
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