What Can I Say, What Can’t I Say?
If a friend or family member asks for information regarding a specific patient—BY NAME, you may:
| Disclose | Don’t Disclose |
|---|---|
Location of the patient and general condition:
| Specific conditions: |
| PHI for treatment, payment, and operations (TPO) | PHI for other than TPO |
| Treatment, payment, and health care operations | “PHI is never given out without authorization; if you obtain signed authorization from the patient, I can release the requested information.” |
| Any DII | DII can be disclosed without consent because personal identifiers are omitted in the data (used for research, public health, etc.). |
Authorization to Release Health Care Information
Patient ______________________________________________________
Date __________________________________________________________
Patient ID# __________________________________________________
I request and authorize ______________________________ office to release the health care information of ______________________ (patient name) to (name and address of destination of the medical information):______________________________________________________________
This request and authorization applies to (sign appropriate lines):
I understand that my expressed consent is required for release of information relating to diagnosis and treatment of sexually transmitted diseases, HIV/AIDS, drug and alcohol abuse, and psychiatric disorders and mental health care. If I have been tested, diagnosed, or treated for the aforementioned, permission by my signature at the item authorizes you to release information regarding that testing, diagnosis, and/or treatment.
Signature of patient or authorized representative _____________________________
Relationship to patient _______________________
Date _____________________