Healthcare Clinical Use Example

HEALTHCARE CLINICAL USE EXAMPLE

Patient Information

Date of Birth:    Gender:    Phone:

Relationship:    Phone:

Insurance Information

Policy/ID Number:    Group Number:

Medical History (Brief)

Description of Clinical Use

Provider Name:

Authorization for Use and Disclosure of Protected Health Information

I authorize the health care provider named above and its agents to use and disclose my protected health information (PHI) as described in this form for the purposes indicated. PHI to be used or disclosed may include, but is not limited to, medical records, clinical notes, imaging studies, photographs, audio recordings, video recordings, and other diagnostic materials. This authorization permits disclosure of PHI to other health care professionals, educational entities, quality improvement programs, and research entities where data is de-identified unless otherwise specified below.

Purpose(s) of disclosure:

  Use for clinical training and education (including case presentations)
  Use for quality improvement, performance review, and internal audits
  Use for research with de-identified data only (no direct identifiers)
  Use in academic publications or presentations (identifiable information will not be published unless specifically authorized)
  Audio or video recording of clinical encounters or procedures
  Photographs or clinical images for documentation or teaching
  Other:

Risks, Benefits, and Alternatives

I understand that the potential benefits of authorizing use of my PHI for the purposes described include contribution to medical education, improved quality of care, and advancement of medical knowledge. I understand the risks include potential unauthorized disclosure of identifiable information and that absolute confidentiality cannot be guaranteed. I understand that I may refuse or limit this authorization and that refusal will not affect my ability to obtain treatment, payment, enrollment, or eligibility for benefits except where disclosure is required to carry out the requested activity.

Duration and Revocation

This authorization is valid until: . If no date is provided, this authorization will expire one year from the date of signature. I understand I may revoke this authorization at any time by providing a written notice to the provider, except to the extent that action has already been taken in reliance on this authorization.

Redisclosure and Third Parties

I understand that once my PHI is disclosed pursuant to this authorization to entities not covered by the same privacy protections, the information may be subject to redisclosure by those entities and no longer protected by federal privacy regulations. The provider will make reasonable efforts to ensure third parties who receive identifiable information agree to limit their use in accordance with this authorization.

Acknowledgments and Certifications

  I acknowledge that I have received or been offered a copy of the provider's privacy practices and notice of privacy rights.

  I understand that signing this authorization is voluntary and that I will not receive financial compensation for disclosures authorized herein.

  I have had the opportunity to ask questions about the clinical use described and my questions have been answered to my satisfaction.

Patient Certification

By signing below I certify that I am the patient or the patient's authorized representative, that I have read and understand the terms of this authorization, and that the information I have provided is true and correct to the best of my knowledge. I understand that a copy of this signed authorization will be as valid as the original.

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