TENNESSEE DEPARTMENT OF HUMAN SERVICES
HIPAA AUTHORIZATION FOR RELEASE OF MEDICAL/HEALTH INFORMATION
TO 3RD PARTY
Information will be released for: |
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Identify Signer: |
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PRINT NAME► |
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Self |
Parent of minor |
Guardian |
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Other authorized representative (explain) *Proof of legal authorization |
Street Address |
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may be required. |
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(Parent/guardian sign here if two |
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signatures required by State law) |
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Phone Number (with area code) |
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I give permission for the following medical/health records about me to be released by the Tennessee Department of Human Services (TDHS) and its authorized agents/contractors to the persons/organizations and for the purposes described below:
•Specific Description of medical/health information to be provided *Additional approval required for certain records)
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•*TDHS can also release drug or alcohol treatment/referral records: Yes:_____ No:____
•*TDHS can also release HIV/AIDS test/treatment records: Yes _____ No:_____
•TDHS can release my medical/health information to the following persons/organizations:
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•My medical/health records will be used for the following purposes: ___________________________________________________
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For the medical/health records I have given permission to be disclosed, TDHS can talk to, or give copies of my medical/health records to any of the person/organizations I have permitted and can give this information by paper, fax, computer or electronic copies of those records.
YOU DO NOT HAVE TO SIGN THIS FORM. I understand that my eligibility for benefits or services from the Tennessee Department of Human Services will not be affected if I do not sign this form.
•I will get a copy of this form after I sign it. I can ask TDHS to let me see a copy of the information it sends after I sign this form.
•This permission is good for 12 months from the date I sign this form, unless I take back my permission sooner.
•You have the right to withdraw your permission at any time. You cannot take back information that has been given to other persons/organizations before you take back your permission and it will not affect any actions taken before you take back your permission.
•To take back your permission to let us give your medical/health records to other persons/organizations, you can write TDHS in your county, or write the persons/organizations that you have said we can give your information to. I understand that the person or organization that I have given permission to get my medical/health information may not be required by law to protect that information under federal or state law or regulations.
•Ask TDHS to explain if you have questions about what information was given to any person or organization.
Signature of Person or Person’s Authorized Representative: ___________________________ Date:_________________
This authorization was developed to comply with the provisions regarding disclosure of medical/health information under P. L. 104-191 (“HIPAA”); 45 Code of Federal Regulations parts 160 and 164; 42 U.S. Code Section 290dd-2; 42 CFR part 2.31; 38 U.S. Code section 7332 and T.C.A § 68-10-113.
HS-2939 (Revised 01/2007) HIPAA Authorization for Release of Medical/Health Information By TDHS to 3rd Party (English)
