Healthcare CDA Draft

Healthcare CDA Draft Authorization for Creation and Disclosure of Clinical Document

This Authorization permits the preparation, compilation, and limited disclosure of a Clinical Document Architecture (CDA) draft containing Protected Health Information (PHI) for the purposes and recipients specified below. Completion of this form constitutes written authorization under applicable health information privacy laws.

Patient Identification

Patient Name:    Date of Birth:

Insurance Information

Medical History Summary (for CDA Draft)

Authorization Details

I authorize the preparation of a CDA draft that consolidates clinical data from the health record described above. The CDA draft may include but is not limited to: problem lists, medication lists, allergies, lab results, radiology summaries, clinical notes, and immunizations. Preparation and disclosure are limited to the purpose and recipients identified below.

Include the following categories of sensitive information in the CDA draft (select all that apply). If none are selected, such information will be excluded unless otherwise required by law.

Limits, Expiration, and Revocation

This authorization is valid for the creation and disclosure of the CDA draft for the period specified below, unless revoked earlier in writing. I understand that I may revoke this authorization at any time by delivering written notice to the health information custodian; revocation will not apply to disclosures already made in reliance on this authorization.

Exceptions: This authorization does not authorize use or disclosure of psychotherapy notes or other specially protected records unless explicitly indicated above. It does not authorize release of records beyond the recipient identified except as required for the stated purpose.

Re-disclosure and Acknowledgments

I understand that once the CDA draft is disclosed to the recipient named above, the information may be subject to re-disclosure by that recipient and may no longer be protected under applicable privacy rules. The health information custodian and its workforce are released from liability that may arise from release of the information as authorized herein.

I understand I may be charged a reasonable, cost-based fee for preparation, copying, and transmission of the CDA draft where allowed by law.

By signing below I acknowledge that I have been given the opportunity to review the organization's privacy practices and that I authorize the actions described in this form.

Certification and Signature

I certify that I am the patient or the patient's representative with authority to make this authorization. I understand the nature and purpose of this authorization and that I may refuse to sign without affecting my ability to obtain treatment, payment, or eligibility for benefits.

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