In today's healthcare landscape, the protection and lawful sharing of individual health information is paramount, guided by comprehensive federal regulations such as the Health Insurance Portability and Accountability Act (HIPAA). A core component ensuring compliance and respect for patient privacy is the WCIF/WCIP Authorization for Release of Protected Health Information form. This document serves a critical function within Washington Counties Insurance Fund (WCIF) and Washington Counties Insurance Pool (WCIP), facilitating the authorized exchange of protected health records between healthcare providers, insurance carriers, and other relevant entities. It outlines the conditions under which a patient's health information can be disclosed, emphasizing the voluntary nature of such disclosures. Specifically, it addresses the fundamentals around patient consent, the scope of information to be shared, the duration of the authorization, and the rights of the patient regarding the revocation of consent and access to their information. It also underscores that executing this form is not a prerequisite for receiving health care benefits, while illuminated is the potential for re-disclosure by third parties, which may no longer protect the information under HIPAA. The content and completion requirements of the form are designed to ensure patients are fully informed and consenting participants in the management of their health information. This highlights a balance between regulatory compliance and the empowerment of patients in the decision-making processes related to their personal health data.
| Question | Answer |
|---|---|
| Form Name | Wcif Form Lb |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | Authorization for Release of PHI kansas 2015 hipaa consebnt form for patient printable |
WCIF/ WCIP Authorization for Release of Protected Health Information Pursuant to HIPAA by WCIF, Affiliated Health Insurance Carriers, and Business Associates
WASHINGTON COUNTIES INSURANCE FUND
WASHINGTON COUNTIES INSURANCE POOL
Patient Name
Date of Birth
Social Security Number
Patient Address (Street | City | State | Zip)
Phone Number
Patient Email Address
I hereby voluntarily authorize the use or disclosure of my protected health information as described below.
Unless revoked, this authorization will expire either a) within 90 days, or b) when my current issue is resolved (whichever is less).
Please read the following and initial below.
•I may revoke this authorization at any time prior to its expiration date shown below by notifying in writing the organization authorized to provide my protected health information (WCIF | PO Box 7786 | Olympia, WA | 98507 | (800)
•If I revoke this authorization, I understand the revocation will not affect any uses or disclosures of my protected health information made by the providing organization before it received my revocation.
•I may see and copy the information described on this form if I request it (via either written or oral request).
•I am not required to sign this form to receive my health care benefits (enrollment, treatment, or payment).
•The information that is used or disclosed because of this authorization may be
•This form must be completed in its entirety before signing.
I have read and understand my rights regarding the privacy of my protected health information. _________
Initials
Name and address of health provider or entity to release this information:
Name and address of person(s) or category of person to whom this information will be disclosed:
Specific information to be released:
Health information from (insert date) _________________ to (insert date) ____________________
Entire record of health information as kept by WCIF/WCIP and affiliated health insurance carriers including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance records and records sent to you by other health care providers.
Billing and/or claims information. |
Include: (Indicate by initialing) |
Other: ___________________________ |
_________ Alcohol/Drug Treatment Information |
___________________________ |
_________ Mental Health Information |
|
_________ |
|
_________ Genetic Testing Information |
Authorization to Discuss Health Information |
|
By initialing here _______ I authorize _______________________________________________________________
Initials |
Name of individual / health care provider |
to discuss my health information with my attorney, or a governmental agency listed here:
______________________________________________________________________
|
Attorney/Firm name of Governmental Agency Name |
||
|
|
|
|
Reason for release of information: |
|
|
|
At request of patient |
Other: |
|
|
If not the patient, name of person signing form:
Authority to sign on behalf of patient:
All items on this form have been completed and my questions about this form have been answered. In addition, I have retained a copy of this form.
Signature of patient or representative authorized by law |
Date | Please note that this authorization will |
(Note: Form must be completed before signing.) |
expire the lesser of 90 days or the date upon |
YOU MAY REFUSE TO SIGN THIS AUTHORIZATION. |
which your current issue is resolved. |
LB(030911)