Missouri Hipaa Form PDF Details

In the realm of healthcare legislation, the Missouri HIPAA Privacy Authorization Form stands as a crucial document delineating the permissible contours of personal health information disclosure. Required by the Health Insurance Portability and Accountability Act (HIPAA), this document serves a pivotal role by bridging the gap between privacy rights and the need for information in a healthcare context. The form essentially allows individuals to grant authorization for the use or disclosure of their protected health information, specifying the extent and terms of this disclosure. It encompasses a broad spectrum of information, including all-encompassing health records or excluding sensitive details like mental health care or substance abuse treatment, subject to the individual's discretion. Moreover, it emphasizes the power of individuals to direct the use of their medical information for various purposes, whether for medical treatment, billing, or other personal directives. Alongside these provisions, the form includes safeguards such as the ability to revoke the authorization at any time and clauses ensuring that the individual's access to treatment or insurance benefits is not contingent upon their consent to the disclosure. Additionally, it recognizes the temporal boundaries of consent, with each authorization expiring on a specific date or event. However, it also notes a critical caveat: once shared, the disclosed information might escape the protections afforded by federal and state law. Authored under the auspices of the Missouri Attorney General's Office, this form embodies a nuanced balance between regulatory demands and the imperatives of individual autonomy and privacy in healthcare.

QuestionAnswer
Form NameMissouri Hipaa Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesmo hipaa authorization, mo hipaa form, missouri hipaa authorization, mo hipaa authorization form

Form Preview Example

HIPAA Privacy Authorization Form

Return to: Missouri Attorney General’s Office

Attn: Jodi Lehman

Authorization for use or disclosure of protected health information.

PO Box 899

(Required by the Health Insurance Portability and Accountability Act

Jefferson City, MO 65102

– 45 CFR Parts 160 and 164)

MISSOURI ATTORNEY GENERAL

573-751-3321

CHRIS KOSTER

AGO.MO.GOV

1

I hereby authorize

 

 

to use and/or disclose the

 

 

NAME OF HEALTH CARE PROVIDER

 

 

protected health information described below to

 

 

.

NAME OF INDIVIDUAL

 

 

 

 

 

2

Authorization for Release of Information. Covering the period of health care from

to

 

 

OR

All past, present and future periods:

 

 

 

 

 

 

a

 

I hereby authorize the release of my complete health record (including records relating to mental health care,

 

 

communicable diseases, HIV or AIDS, and treatment of alcohol/drug abuse).

 

 

 

 

 

 

 

 

OR

 

 

 

 

 

 

b

 

I hereby authorize the release of my complete health record with the exception of the following information:

 

 

 

Mental health records

Communicable diseases (including HIV and AIDS)

 

 

Alcohol/drug abuse treatment

Other:

 

 

 

 

3

4

5

6

7

This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.

This authorization shall be in force and effect until

 

,

at which time this authorization expires.

DATE OR EVENT

I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

I understand that my treatment, payment, enrollment or eligibility for benefits will not be conditioned on whether I sign this authorization.

I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.

SIGNATURE OF PATIENT OR PERSONAL REPRESENTATIVE

DATE

PRINT NAME OF PATIENT OR PERSONAL REPRESENTATIVE

RELATIONSHIP TO PATIENT

APRIL 2009

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Part # 1 for completing hipaa release form missouri

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Completing part 2 of hipaa release form missouri

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