Authorization for Release of Medical Records + Attestation Regarding a Requested Use or Disclosure of Protected Health Information Potentially Related to Reproductive Health Care

Ignite Counseling Colorado

Email: Hello@ignitecounselingcolorado.com

(303) 578-6336

The entire form must be completed for the attestation to be valid.

1) Name of person(s) orspecific identification of the class of persons to receive the requested PHI.

e.g., name of investigator and/or agency making the request

2) Name or other specific identification of the person or class of person from whom you are requesting the use or disclosure.

e.g., name of covered entity of business associate that maintains the PHI and/or name of their workforce members who handles requests for PHI

3) Description of specific PHI requested, including name(s) of individual(s), if practicable, or a description of the class of individuals, whose protected health information you are requesting.

eg., visit summary for [name of individual] on [date]; list of individuals who obtained [name of prescription medication] between [date range]

I attest that the use or disclosure of PHI that I am requesting is not for a purpose prohibited by the HIPAA Privacy Rule at 45 CFR 164.502(a)(5)(iii) because of one of the following (check one box):

The purpose of the use or disclosure of protected health information is not to investigate or impose liability on any person for the mere act of seeking, obtaining, providing, or facilitating reproductive health care or to identify any person for such purposes.

The purpose of the use or disclosure of protected health information is to investigate or impose liability on any person for the mere act of seeking, obtaining, providing, or facilitating reproductive health care, or to identify any person for such purposes, but the reproductive health care at issue was not lawful under the circumstances in which it was provided.

I understand that I may be subject to criminal penalties pursuant to 42 U.S.C. 1320d-6 if I knowingly and in violation of HIPAA obtain individually identifiable health information relating to an individual or disclose individually identifiable health information to another person.

I understand that if I choose to have my records sent electronically via encrypted email, there is a riskthat electronic communications may be compromised, unsecured, and/or accessed by a third party despite Ignite sending such records in a secure and encrypted format. If I chose this format, I acknowledge those associated risks.

I understand that if I choose to have my records sent via USPS, there is a risk that paper mailed communications may be compromised, unsecured, and/or accessed by a third party. If I chose this format, I acknowledge those associated risks.

Authorization for Release of Medical Records

Requests are completed within 14 business days of submitted request.

Name of Client (First, Last)

Name of Person Completing Form (if different than client)

Relationship to Client (if person completing form is not client)

Email address

Last four digits of SSN of client:

Type of Information to be released (List as specifically as possible, for example: dates of service, psychotherapy notes, diagnoses, etc).

Purpose for Information Release (List as specifically as possible, for example: to receive benefits, for legal action).

Release Information to the Following:

Name (First, Last)

Phone Number

Email address

Delivery Method:

Encrypted Email

Mail- USPS

Records are being requested for the following purpose:

Continued medical care

Legal Purposes

Insurance Purposes

Personal Interest

Other

Where records should be sent (if being mailed):

Street Address, City, State/Province, Postal/Zip Code

Release Date Expiration (recommendation is one year past today's date but cannot be longer than two years past today's date)

I understand that this release is valid when I sign it and that I may withdraw my consent to this release at any time either orally or in writing.

E-Signature: Type in your First and Last Name. I agree that my signature on this document (hereafter referred to as your "E-Signature" is as valid as if I signed the document in writing.

Your information will be encrypted.