What is and how to fill out an Authorization to Release Protected Health Information

Protected Health Information

Your health information falls under specific protections per federal law. In order to release the information the authorization form must be completed and signed before any release of your mental health information to a third party.

Key Terms

HIPAA is the federal Health Insurance Portability and Accountability Act of 1996. The primary goal of the law is to make it easier for people to keep health insurance, protect the confidentiality and security of healthcare information and help the healthcare industry control administrative costs.
Protected Health Information

protected health information (PHI) is individually identifiable information (see below for definition) that is:

  1. except as provided in item 2 of this definition,
    1. transmitted by electronic media;
    2. maintained in electronic media; or
    3. transmitted or maintained in any other form or medium (includes paper and oral communication).
  2. Protected health information excludes individually identifiable health information:
    1. in education records covered by the Family Educational Rights and Privacy Act, as amended, 20 U.S.C. 1232g;
    2. in records described at 20 U.S.C. 1232g(a)(4)(B)(iv);
    3. in employment records held by a covered entity (see below for definition) in its role as employer; and
    4. regarding a person who has been deceased for more than 50 years.

    All protected health information is subject to federal Health Insurance Portability and Accountability Act (HIPAA) regulation.

Individually Identifiable Health Information
Individually identifiable health information is information that is a subset of health information, including demographic information collected from an individual, and
  1. is created, or received by a health care provider, health plan, or health care clearing house; and
  2. relates to past, present, or future physical or mental health conditions of an individual; the provision of health care to the individual; or past, present, or future payment for health care to an individual, and
    1. that identifies the individual; or
    2. with respect to which there is a reasonable basis to believe the information can be used to identify the individual.
    3. Individually identifiable health information (i.e., PHI) is subject to state and federal privacy and security rules including, but not limited to, the Health Insurance Portability and Accountability Act (HIPAA).
Covered Entity
A covered entity is any health plan, health care clearing house, or health care provider who transmits any health information in electronic form in connection with a qualified transaction and their business associates. Indiana University has designated itself as a Hybrid Covered Entity and all IU HIPAA Affected Areas are expected to adhere to the HIPAA Privacy and Security Rules as well as any other area or unit that creates, uses, or stores PHI from another HIPAA Affected Area or outside covered entity.

Data are "individually identifiable" if they include any of the 18 types of identifiers for an individual or for the individual's employer or family member, or if the provider or researcher is aware that the information could be used, either alone or in combination with other information, to identify an individual. These identifiers are:

  • Name
  • Address (all geographic subdivisions smaller than state, including street address, city, county, or ZIP code)
  • All elements (except years) of dates related to an individual (including birth date, admission date, discharge date, date of death, and exact age if over 89)
  • Telephone numbers
  • FAX number
  • Email address
  • Social Security number
  • Medical record number
  • Health plan beneficiary number
  • Account number
  • Certificate/license number
  • Vehicle identifiers and serial numbers, including license plate numbers
  • Device identifiers or serial numbers
  • Web URLs
  • IP address
  • Biometric identifiers, including finger or voice prints
  • Full-face photographic images and any comparable images
  • Any other unique identifying number, characteristic, or code

How To fill out your authorization

The authorization will need to be completed as follows:

  • Section 1: The patient must fill in the blanks with their first, middle and last name
  • Section 2: The patient must fill in the blanks with their date of birth
  • Section 3: Enter the current date.
  • Section 4: Enter the name of whomever is completing this form
  • Section 5: Check "Authorization for Psychotherapy Notes Only" if you need information about your session notes released. Any other information to be released then check “Other” and in the blank enter what you require to be released. If you are unsure, contact Dr. Dane for guidance.
  • Section 6: Check which ever box more closely describe the reason for your disclosure
  • Section 7: Enter “Dr Robert M Dane, Ph.D. LPC-S, LCDC”
  • Section 8: Enter the name, address, phone number ,fax number and email address of the third party you want your information to be released to
  • Section 9: Enter a date for the expiration of this authorization or a condition for the authorization to expire (Example: 30 days from the authorization date, 60 days from the authorization date etc.)

Dr. Robert M Dane Ph.D.
Dr. Robert M Dane Counseling Services PLLC
101 West Cooperative Way, Suite 238
Georgetown, TX, 78626 USA

Texas Licensed Professional Counselor and Counselor Supervisor - License Number 14671

Texas Licensed Chemical Dependency Counselor - License Number 10667

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